Clinical Documentation Specialist RN

The Clinical Documentation Improvement Specialist (CDIS) will facilitate the improvement of clinical documentation in the medical record to reflect an accurate level of care and diagnosis for our patients. The CDIS will obtain and promote the appropriate clinical documentation through interaction with physicians, nursing staff, and Health Information Management (HIM) Coders.

Full Time

8:00 AM - 5:00 PM

• Provides concurrent review of the clinical documentation in medical records.
• Concurrently queries the medical staff and other caregivers as necessary via written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
• Reviews medical records for opportunities for diagnosis clarification and validity as it pertains to DRG assignment.
• Performs a thorough chart review to identify comorbidities/complications and documents these appropriately.
• Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
• Able to navigate within the electronic healthcare record (EHR) to obtain accurate and complete physician documentation of signs and symptoms, co‑morbidities, disabilities, and other pertinent information in regard to level of care and diagnosis of the patient.
• Adheres to all coding and clinical documentation improvement guidelines by AHIMA and ACDIS.
• Develops and presents ongoing documentation education for the clinical staff team.

• Must be a high school graduate or equivalent.
• Registered Nurse – current license (ADN or BSN) with 5 years acute care experience or a comparable degree in a healthcare-related discipline with 3–5 years recent coding experience and certification of one of the following preferred:
  Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS).
• Strong broad-based clinical knowledge and understanding of pathology/physiology.
• Knowledge of age‑specific needs and the elements of disease processes and related procedures.
• Able to convert weights and measures for clinical application.
• Ability to analyze collected data to define and address issues.
• Excellent written and verbal communication skills and critical thinking skills.
• Computer literacy and familiarity with the operation of basic office equipment.
• Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear.
• Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non‑clinical staff. The individual must use an assisted‑lift device or obtain assistance from others to lift over these limits.