RN, Clinical Documentation Specialist

Extensive record review, interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the CDI process is a key role. Ability to learn/develop the skills necessary to perform CDI duties. Accurate and timely record review. Recognize opportunities for documentation improvement. Formulate clinically credible queries. Effective and appropriate communication with physicians. Timely follow up on all cases especially those with queries. Participate in Task Force meetings. Manage multiple priorities. Communicates with HIM staff and resolves discrepancies. Accurate input of data into the electronic medical record. Understand and support clinical documentation strategies. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments. RN, Clinical Documentation Specialist – Grade: NSI4, Job Code: 3057 Graduate of a School of Nursing (RN) - Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts (BSN) – A Bachelor of Science in Nursing (external applicants only) Minimum of 3 years of current RN, CDI Practice experience Must meet at least one of the following qualifications: Certified Clinical Documentation Specialist (CDI) CCHC Clinical Documentation Specialist Exam Knowledge of Medicare Part A and Part B Knowledge of regulatory environment Organizational, analytical, writing and interpersonal skills Dependable and self-directed Critical thinking, problem solving and deductive reasoning skills Knowledge of pathophysiology and disease process Basic computer skills – familiarity with Windows based software programs Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers

The Clinical Documentation Specialist is responsible for performing accurate record reviews and facilitating documentation improvement through effective communication with physicians and HIM staff. They also provide staff education on CDI processes and ensure data is accurately entered into the electronic medical record.

Candidates must be a Registered Nurse with a Bachelor of Science in Nursing and at least 3 years of current CDI practice experience. Additionally, applicants must hold a relevant certification such as CCDS or CCHC and possess strong knowledge of Medicare guidelines and pathophysiology.

• Résolution de problèmesSouhaitée
• Regulatory ComplianceSouhaitée
• interpersonal skillsSouhaitée
• NegotiationSouhaitée
• Critical ThinkingSouhaitée
• Saisie de donnéesSouhaitée

Relevées dans la description du poste. Confirmez les exigences importantes ci-dessus.

• Clinical Documentation Improvement
• Record Review
• Physician Communication
• Medicare Part A
• Medicare Part B
• DRG Assignment
• Pathophysiology
• Disease Process
• Critical Thinking
• Problem Solving
• Data Entry
• Negotiation
• Interpersonal Skills
• Analytical Skills
• Regulatory Compliance
• Clinical Documentation
• DRG (Diagnosis-Related Group) Assignment
• Registered Nurse (RN)
• Regulatory Environment
• Bachelor Of Science in Nursing (BSN)
• Certified Clinical Documentation Specialist (CCDS)
• Self-Discipline
• Positivity
• Communication
• Computer Literacy
• Deductive Reasoning
• Interpersonal Communications
• Medicare
• Nursing

• Healthcare
• Administrative
• Clinical Documentation Specialist Registered Nurse
• Document Control / Management Specialist
• Filing and Copying Clerks
• Document Management Specialists
• Computer Occupations, All Other

Formation minimale

Diplôme professionnel

Expérience minimale

2+ ans

Langue de l’offre

anglais

Heures de travail

40 heures par semaine