Associate Clinical Documentation Specialist (RN)

Yale New Haven Health • New Haven, CT

1d

About The Position

The Associate Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through extensive, real-time interactions with physicians and other clinicians. The role helps ensure that documentation reflects appropriate clinical severity, complications, and comorbidities, while concurrently reviewing selected patient medical records for integrity, quality, and completeness. The specialist reviews records to identify diagnoses, procedures, and a working DRG, and collaborates with coding staff and providers to support accurate, compliant documentation and coding.

Requirements

• Active RN license required.
• At least three years of recent inpatient acute care nursing experience required.
• Clinical expertise required.
• Excellent communication, negotiation, and organizational skills.
• Ability to adapt to a wide variety of interpersonal encounters with the hospital team.
• Comprehensive understanding of using medical records to extract data.
• Willingness to learn clinical and coding concepts.
• Working knowledge of third-party and prospective payment systems.
• Computer literacy and ability to work on various software platforms.
• Ability to work collaboratively and independently.
• Flexibility with responsibilities to meet departmental needs.
• Keen attention to detail.
• Ability to communicate clearly and confidently with providers about program goals and documentation issues through email, in-person communication, telephone, and other written and electronic forms.

Nice To Haves

• Bachelor of Science in Nursing.
• Recent ICU experience.

Responsibilities

• Review hospitalized patients’ medical records to identify the most appropriate principal diagnosis, secondary diagnoses, procedures, and working DRG.
• Perform initial, concurrent, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
• Ensure the working DRG and comorbid conditions are documented by providers to the greatest specificity.
• Collaborate with coding staff concurrently and retrospectively to ensure charts contain the documentation needed to support accurate coding.
• Develop and maintain strong professional relationships with CDS and coding staff, physician leadership, and clinicians across the system.
• Use a compliant query process in accordance with guidelines and policy, and follow each query through closure with complete documentation of follow-up activities and communication.
• Work collaboratively with licensed independent providers to support positive program outcomes.
• Share professional knowledge and provide ongoing learning opportunities for the CDS team.
• Maintain integrity and compliance in chart reviews, CDI documentation, and queries.
• Support and implement quality measures identified by department management.
• Maintain an audit score greater than 95%.
• Identify and implement performance improvement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed