Clinical Documentation Improvement Specialist RN

Prime Healthcare • Lewiston, ME

15h

About The Position

Overview Central Maine Healthcare is an integrated healthcare delivery system serving 400,000 people living in central, western and Midcoastal Maine. CMH's hospital facilities include Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital. CMH also supports Central Maine Medical Group, a primary and specialty care practice organization. Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services. Responsibilities The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. He/She will perform other duties as assigned or required.

Requirements

• Medical Graduate, PA or Nursing Graduate
• Minimum of one (1+) year’s clinical experience in an acute care setting
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written, and verbal communication skills and critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.

Nice To Haves

• ECFMG Certificate or RN license
• Prior Case Management Experience
• Working knowledge of the Medicare reimbursement system and coding structures
• Current BCLS (AHA) certificate upon hire and maintain current.
• ACLS Certificate

Responsibilities

• Conducting clinically based concurrent and retrospective reviews of inpatient medical records.
• Evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided.
• Works closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.
• Perform other duties as assigned or required.

What This Job Offers

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