CDI Specialist-Health Information Management

Overview

The Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other healthcare team members, the Clinical Documentation Specialist will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.

This position will actively participate in educating appropriate hospital and medical staff about the changes associated with transitioning to ICD-10.

Minimum Education:

Graduate of a School of Nursing program.

Minimum Experience:

Minimum of five years experience in a clinical role and a minimum of two years experience with inpatient coding, process improvement in an acute care facility preferred or equivalent experience. Coding skills with experience in ICD-9-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic. Prior experience in quality, case management, clinical documentation improvement, and/or coding accuracy preferred.

Certified Documentation Improvement Specialist (CDIS) preferred.

Current working knowledge of one or more of the following:
Medical /Surgical Nursing, Critical Care, Care and Case Management (Resource Utilization), Surgical Services, Perinatal Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data.

Certification/Licensure:
Current New Mexico or compact RN license required.