Clinical Documentation Specialist RN

Intrastaff • Baltimore, MD

10h • Remote

About The Position

The Clinical Documentation Specialist (CDS) is responsible for distributing documentation information to respective departments; performing educational outreach to individual units and provider groups along with the CDS assigned to those units; supports training of new staff members; and the design and development of educational tools for staff and Providers. This role facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment, severity level and reimbursement. This role functions as subject matter liaison, leads and manages documentation improvement initiative, serves on internal hospital committees. CDS will obtain appropriate documentation through interactions with physicians and collaboration with other departments. Additional responsibilities as assigned.

Requirements

• Comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems.
• Strong background knowledge of disease processes and pharmacology.
• College-level knowledge of Medical Terminology.
• Complete and thorough understanding of the unique functions of each clinical area.
• In-depth knowledge of clinical coding processing and documentation standards, guidelines, policies, and procedures.
• Must be conversant in clinical documentation improvement.
• High level of proficiency in adult education and training.
• Thorough understanding of Hospital bylaws and Joint Commission standards related to departmental activities.
• Clinical pertinence requirements and proficiency in abstraction and data entry into all the database systems used for clinical documentation.
• Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.
• Understanding of HSCRC, Maryland Quality Improvement Programs and CMI impact on hospital budget.
• Knowledge of Healthcare Insurance Portability and Accountability Act (HIPAA).
• Must be conversant in: ICD-10-CM, APRDRGs, DRGs.
• Strong interpersonal, communication (verbal, non-verbal, and listening) skills.
• An understanding of adult learning theory, instructional design, and critical thinking.
• Operating at competent level with, but not limited to: Microsoft Office Suite, web-browsers, email, electronic health records, online collaboration software, virtual meeting applications.
• Strong interpersonal skills and ability to effectively communicate with team members.
• Ability to work in a dynamic, team-oriented environment.
• Ability to work independently and be self-directed.
• Ability to work under pressure to meet submission, project, and reporting deadlines.
• Ability to work in a fast-paced academic teaching hospital.
• Requires successful completion of: Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR successful completion of an AMA approved Physician Assistant program, OR successful completion of the academic requirements of Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
• Active RN License.
• EPIC experience (12) months current RN experience in similar role in MD or nationally using MSDRG.
• Medicare Coding regulations 2024.
• A minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting.
• Minimum of 2 years as a Clinical Documentation Specialist required.
• In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered.

Responsibilities

• Distributing documentation information to respective departments.
• Performing educational outreach to individual units and provider groups along with the CDS assigned to those units.
• Supporting training of new staff members.
• Designing and developing educational tools for staff and Providers.
• Facilitating the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment, severity level and reimbursement.
• Functioning as subject matter liaison.
• Leading and managing documentation improvement initiatives.
• Serving on internal hospital committees.
• Obtaining appropriate documentation through interactions with physicians and collaboration with other departments.
• Additional responsibilities as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree