Clinical Documentation Specialist

Other jobs >> General

Negotiable

Permanent

Description

Clinical Documentation Specialist



Save JobJob Saved



Job IDREQ_******FACILITYRiedman CampusLOCATIONRochester, New York



SUMMARY



The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with physicians, health information management professionals, and nursing staff.



STATUS: Full Time



LOCATION: Riedman Campus



DEPARTMENT: Health Information Management



SCHEDULE: M-F Days



Job Responsibilities:



- Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality



- Accurate and timely record review



- Recognize opportunities for documentation improvement



- Formulate clinically credible documentation clarifications



- Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety



- Effective and appropriate communication with physicians



- Provides education to members of the patient care team regarding the CDS process.



- Timely follow up on all cases and resolution of those with clinical documentation clarifications



- Actively participate in Team Meetings



- Manage multiple priorities



- Communicates with HIM staff and resolves discrepancies



- Accurate input of data into department software



Desired Skills:



- Ability to learn/develop the skills necessary to perform the CDS role



- Organizational, analytical, writing and interpersonal skills



- Dependable, self-directed and pleasant



- Critical thinking, problem solving and deductive reasoning skills



- Knowledge of Pathophysiology and Disease Process



- Basic Computer skills - familiarity with Windows based software programs



- Knowledge of regulatory environment



- Understand and support CDS documentation strategies (upon completion of training)



- Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)



- Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)



Minimum Qualifications:



- 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.



- Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.



- Previous CDS experience preferred



Required Licensure/Certification:



- RN, PA, NP or MD prepared candidates



- If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire



- CCDS certification not required for legacy Unity team members hired before 12/31/2016.



Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran
  • 1
  • Negotiable
  • None
  • None
  • Re-207872
  • Permanent
  • 0

How to Apply: Please click here to create a free Pure-jobs.com account and post your resume. Only logged in job seekers can apply for a job.

Find us at:

Never provide bank account, credit card details or any other financial information, or make any form of payment, when applying for a job. If you are ever asked to do this by a recruiter on Pure Jobs please click the Report button or contact us with the advertiser's company name and the title of the job vacancy. You should not send any money to anyone. A genuine employer with a job offer would never ask you to do this.

Report this job
x

Report a job

If you're concerned about a job advert, let us know and our quality team will investigate.

Your name(*)
Invalid Input

Your email address(*)
Invalid Input

Please select you reason(*)

Additional information(*)
Invalid Input

Invalid Input



Subscribe to updates from our blog

PLEASE NOTE! WE USE COOKIES AND SIMILAR TECHNOLOGIES FOR THE BEST USER EXPERIENCES

However, by continuing to use the site without changing settings, you are agreeing to our use of cookies.