Clinical Documentation Specialist - CDI Clinical Documentation (Full Time) - 7184

Marshall Health Network • Huntington, WV

3d • Onsite

About The Position

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN for an on-site role. The position ensures that accurate and appropriate physician documentation is present in patient medical records to support coding staff in assigning the most appropriate DRG and to accurately represent severity of illness and risk of mortality.

The specialist conducts extensive medical record reviews and works with physicians, nurse practitioners, physician assistants, and health information management professionals. The role includes querying physicians and other clinicians to obtain additional documentation when needed to provide the most accurate account of a patient's condition. The specialist also reviews charts for medical necessity and communicates educational information to physicians about clinical documentation improvement and the importance of accurate, complete patient records.

Requirements

• Graduate of an approved school of nursing (LPN or RN) and/or possess an AAS in HIM from an AHIMA-accredited program.
• RN candidates must have and maintain current West Virginia licensure.
• At least two years of acute care nursing experience and/or five years of previous experience as a Clinical Documentation Improvement Specialist with a CCDS credential.
• Ability to use ICD-10 and PCS coding systems, abstract information from charts, and apply the appropriate DRG.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs, disease processes, and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology and physiology.
• Excellent written and verbal communication skills and critical thinking skills.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to use medical necessity guidelines in relation to the documentation program.
• Ability to stand and walk while performing job responsibilities.
• Working knowledge of the Medicare reimbursement system.

Nice To Haves

• BSN, RN, RHIA, RHIT, CCS, CCDS, CDI-P, or a combination thereof.

Responsibilities

• Review medical records to ensure accurate and appropriate physician documentation supports assignment of the most appropriate DRG.
• Facilitate accurate representation of patients' severity of illness and risk of mortality.
• Interact with physicians, nurse practitioners, physician assistants, and HIM professionals.
• Query physicians and other clinicians to obtain additional documentation when needed.
• Complete chart reviews for medical necessity.
• Educate physicians about clinical documentation improvement and the need for accurate and complete documentation in patient records.

What This Job Offers

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