Clinical Documentation Specialist II

Responsibilities

• Facilitate and obtain quality physician documentation for clinical conditions and procedures.
• Educate the patient care team on documentation guidelines.
• Achieve adherence to departmental and organizational goals, standards, and policies.
• Ensure quality documentation and regulatory compliance.
• Participate in customer service and maintain respectful relationships with team members.
• Contribute to the efficiency and effectiveness of clinical documentation processes.
• Input data into CDI Software accurately and concisely.
• Recognize opportunities for documentation improvement.
• Use critical thinking and sound judgment in decision-making.
• Initiate and formulate CDI severity worksheets and clarifications.
• Transcribe documentation clarifications as appropriate.
• Educate team members on documentation regulations and guidelines.
• Communicate effectively with physicians and other healthcare providers.
• Collaborate with HIM staff to resolve discrepancies.
• Complete well-timed follow-up case reviews.
• Participate in department meetings.
• Maintain a 98% physician response rate to clarifications.
• Assist in new hire orientation.
• Present educational projects to CDI team yearly.
• Review concurrent medical records for compliance, completeness, and accuracy.
• Perform other duties as assigned.

Qualifications

• Excellent interpersonal skills including verbal and written communication.
• Proficient in and demonstrates excellent physician relations.
• Organize and present information clearly and concisely.
• Excellent computer and keyboarding skills.
• Use multiple software programs simultaneously.
• High degree of prioritization skills.
• Learn and develop skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated, and pleasant.
• Demonstrate excellent critical-thinking, problem-solving, and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes, and treatments.
• Strong ability to organize and triage work.
• Knowledge of clinical documentation requirements.
• Coding background.
• Knowledge of quality guidelines.

Education

• Associates degree in nursing or a health-related field.

Work Experience

• 4+ years of acute care nursing experience, including medical/surgical, intensive care, post-acute care unit, or emergency department experience.
• 2+ years of clinical documentation specialist experience.

Additional Information

• Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.
• Licenses and certifications required: Registered Nurse (RN), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP), Advanced Practice Registered Nurse (APRN), Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Educational Commission for Foreign Medical Graduates (ECFMG), Certified Clinical Documentation Specialist (CCDS).

Physical Requirements

View physical requirements here.

Pay Range

$66,170.74 - $123,073.07