Clinical Documentation Specialist Nurse-Safety Sensitive

Job Description

Job Description

Monday-Friday 8-430

Title : Clinical Documentation Specialist (CDS) Nurse-Safety Sensitive

Department : Case Management

Reporting Relationships : Case Management Lead

Case Management Supervisor

Executive Director of Quality

Job Summary : The CDS will facilitate modifications to clinical documentation via compliant query practices. The CDS will utilize extensive concurrent and retrospective medical record reviews and collaborate with providers to reflect appropriate clinical severity, complications, and co-morbidities for the purpose of maintaining quality, integrity, complete and accurate information that is reportable through the ICD-10 coding system.

Job Duties :

• Consistently complies with the guidelines set forth by accrediting bodies.
• Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and assign a working DRG.
• Performs concurrent and retrospective reviews of medical record, to ensure the provider documentation is complete, accurate, and clear, while capturing associated co-morbidities.
• Develops and conducts ongoing CDI education for members of the healthcare team.
• Utilizes compliant query process per guidelines and policy when conducting all queries.
• Support and implement quality measures as identified by department manager.
• Help identify opportunities for performance improvement.
• Utilize Iodine CDI software to guide prioritization of CDI reviews and identifying documentation opportunities.
• Performs other duties as assigned by supervision.
Qualifications :
• Education :
• RN licensure required. (Bachelor’s preferred).
• BLS required.
• Training and Experience :
• 3-5 years clinical experience preferred
• Job Knowledge :
• Knowledge of compliant query practices.
• Demonstration of effective problem-solving techniques including conflict management skills
• Demonstration of excellent oral and written communication skills
• Excellent organizational and record-keeping skills, as well as the ability to manage multiple cases
• Completes responsibilities in a timely manner through effective organization, setting priorities, delegation, and time management skills
• Maintains integrity, confidentiality, and ensures compliance with WRMC’s policies and procedures, regulatory and legal requirements and current health care standards.

Essentials :

Physical Demands : Sitting, standing, walking, and lifting will occur for the majority of the shift. Must be able to lift 20 pounds. Must be able to sit / stand for extended periods of time. Fine motor skills. Visual acuity. Depth perception.