Under general supervision of the CDI Manager, the Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.
Required: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP
Required: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
Required: 0-2 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting
SPECIAL SKILLS: Knowledge of care delivery documentation systems and related medical record documents. Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment. Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff. Computer skills and familiarity with basic office equipment required. Ability to work independently in a time oriented environment. Self-directed, motivated, and possess a positive attitude.
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