RN, Clinical Documentation Specialist

About the Role

The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of physicians’ clinical documentation.

Key activities include extensive record review, interaction with physicians, HIM professionals, and nursing staff, and active participation in team meetings and education of staff in the CDI process.

Responsibilities

• Learn and develop the skills necessary to perform CDI duties
• Perform accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible queries
• Communicate effectively and appropriately with physicians
• Follow up on all cases, especially those with queries
• Participate in Task Force meetings
• Manage multiple priorities
• Communicate with HIM staff and resolve discrepancies
• Accurately input data into the electronic medical record
• Understand and support clinical documentation strategies
• Provide 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

Requirements

• Graduate of a School of Nursing (RN)
• Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
• Bachelor of Science in Nursing (BSN) required for external applicants
• 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

Skills

• 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
• Positive attitude, pleasant, professional, and cooperative demeanor with physicians, fellow employees, and all customers

Schedule

• 40 hours per week
• Monday–Friday, rotating days
• 7:00 AM–3:30 PM
• Rotating weekends and holidays

Pay

Hourly pay range: $42.04 – $89.99