Clinical Documentation Specialist-2,000 Sign on Bonus
Exeter Health Resources and Affiliate Companies | Exeter, NH
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The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. Facilitates the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. Facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. Manages a concurrent query process to accurately capture the appropriate documentation. Responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.
- Registered Nurse (RN), BSN preferred, Certified Coding Specialist (CCS) or RHIA certification required.
- CDIS/CCDS credential preferred or required upon hire or as soon as certification eligibility requirements are met by ACDIS or other similar accredited organization.
- Demonstrated ability to work independently and manage time effectively. Minimum of 3 to 5 years acute care nursing experience or 3 inpatient coding experience. Experience in CDI preferred.
1. Facilitates appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient's past medical history of conditions is appropriately documented.
2. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical record. Discussions with physicians are held in person on the nursing units, via the telephone, email and/or through physician queries.
3. Collaborates with Case Management to ensure that cases are properly documented, to capture patient severity of illness and intensity of service to support medical necessity. Attends rounds for patients on assigned services.
4. Works to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness and/or risk of mortality.
5. Works in tandem with the Director/Manager of Clinical Documentation and Coding and the Clinical Coding Specialists to: educate physicians and caregivers on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling and core measures. Advise and assist in development of documentation education programs. Participate in meetings with physicians for assigned areas to discuss patient care documentation trends and improvement opportunities. Identify educational opportunities with other caregivers and support personnel.
6. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offer solutions and participate in resolution.
7. Assures adherence to Medical Staff Bylaws and Rules & Regulations regarding medical record documentation.
8. Performs and/or coordinates all internal and external audits as assigned by the Director of HIM.