Clinical Documentation Specialist

Clinical Documentation Specialist

The CDS works collaboratively with Coding, Medicine, Nursing, Case Management, the Quality Department and ancillary staff to perform concurrent analytical review of the medical record to ensure an accurate representation of the patients' severity of illness. The goal of the position is to improve documentation of all conditions and treatments from point on entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement.

• Knowledge of pathophysiology and disease process; Medicare Part A and B knowledge of regulatory environment.
• Understanding and ability to communicate the differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.
• Organizational, analytical, writing, and interpersonal skills Dependable, self directed and pleasant; proficiency in organization & planning. Critical thinking, problem solving and deductive reasoning skills.
• Prior experience with computer applications, Windows based software programs and electronic health record required
• Ability to evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation for in-patient encounters that impact the code selection and resulting DRG and / or APR DRG, SOI / ROI groups & payment.
• Knowledge of regulatory environment.
• Must have excellent verbal / written skills and ability to motivate and communicate with other health care professionals.
• Time management skills in order to handle numerous requests simultaneously is required.
• Knowledge of disease processes & procedures. Strong knowledge of anatomy / physiology / pathology.
• Proficiency in data analysis such as, but limited to, database and spreadsheet analysis, presentation programs & Internet searching.
• Must be able to reasonably make appropriate judgment in communications and actions with physicians, other associates, outside agencies, and vendors.

EDUCATION / EXPERIENCE / LICENSURE / TECHNICAL / OTHER :

Education : High School diploma or equivalent required. Bachelor's Degree in Nursing required.

Certification / Licensure : Must have current license from Commonwealth of Massachusetts to practice as a Registered Nurse

Experience : Minimum of five years clinical experience required.

Software / Hardware : Word, Excel, EMR, and experience with 3M 360 and Meditech preferred

Other : Knowledge of Official Coding guidelines preferred

PIdde1d864ea89-30511-37963098