RN, Clinical Documentation Specialist (Per Diem)

Cape Cod Healthcare•Falmouth, MA

6d•Onsite

About The Position

The Clinical Documentation Specialist (CDS) is responsible for extensive record review and interaction with physicians, HIM professionals, and nursing staff. This role actively participates in team meetings and educates staff on the Clinical Documentation Management Program (CDMP®) process. The CDS must be able to learn and develop the skills necessary to perform CDMP®, ensuring accurate and timely record review and recognizing opportunities for documentation improvement. Key responsibilities include formulating clinically credible queries, effective communication with physicians, timely follow-up on cases, and participation in Task Force meetings. The role requires managing multiple priorities, communicating with HIM staff to resolve discrepancies, and accurately inputting data into CDMPTrak®. The CDS must understand and support CDMP® documentation strategies, as well as the differences between Medicare Part A and Part B guidelines and their impact on DRG assignments. The position emphasizes providing service excellence in accordance with Falmouth Hospital’s commitment to CARES: compassion, accountability, respect, excellence, and service.

Requirements

Organizational, analytical, writing and interpersonal skills
Dependable and self directed.
Critical thinking, problem solving and deductive reasoning skills
Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical; or acute care case management experience within the last four (4) years.
Knowledge of pathophysiology and disease process
Basic computer skills – familiarity with Windows based software programs
Knowledge of Medicare Part A and Part B.
Knowledge of regulatory environment
Graduation from a program of nursing
Current Massachusetts Registered Nurse license
Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
Must successfully pass the JATA exam or equivalent clinical assessment exam.

Nice To Haves

Ability to learn/develop the skills necessary to perform CDMP®
Bachelor of Science in Nursing preferred (external applicants only)
Management/supervisory experience preferred

Responsibilities

Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
Active participation in team meetings and education of staff in the CDMP® process.
Accurate and timely record review.
Recognize opportunities for documentation improvement.
Formulate clinically credible queries.
Effective and appropriate communication with physicians.
Timely follow up on all cases especially those with queries.
Participate in Task Force meetings.
Manage multiple priorities.
Communicates with HIM staff and resolves discrepancies.
Accurate input of data into CDMPTrak®.
Understand and support CDMP® documentation strategies.
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.