Clinical Document Specialist II
About The Position
Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
Requirements
- 5 years acute care experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
- 2 years of clinical documentation specialist experience
- Current active State license as a Registered Nurse or Nurse Practitioner or Physicians Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation.
- CCDS (Certified Clinical Documentation Specialist) certification OR
- CDIP (Certified Documentation Improvement Practitioner) certification
Responsibilities
- Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them.
- Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
- Completes accurate and timely record review to ensure the integrity of documentation compliance.
- Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars.
Benefits
- Benefits from Day One
- Paid Days Off from Day One
- Career Development
- Whole Person Wellbeing Resources
- Mental Health Resources and Support
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Ambulatory Health Care Services
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
