Clinical Documentation Specialist
About The Position
The Clinical Documentation Specialist (CDS) communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients/residents. The CDS utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes, provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis related group (DRG). Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team, and gathers and analyzes information pertinent to documentation findings and outcomes. Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization. Must possess advanced communication and interpersonal skills with all levels of internal and external customers. Demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills. Proficient in organization and planning. Possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching. Also demonstrates working knowledge of quality improvement theory and practice. Maintains working knowledge of DRGs and understanding of medical necessity process. Knowledgeable of federal, state, and other payers' regulations, requirements, and criteria. Adheres to ethical and professional business practices, such as the Association of Clinical Documentation Specialists (ACDIS) code of ethics and official coding guidelines. Utilizes the appropriate professional documentation to support daily processes, including white papers published by ACDIS, American Health Information Management Association (AHIMA), and other professional organizations. May perform record reviews on clients in all age groups. Coordinates, facilitates, and negotiates with others. Controls variances and duplication. Must work closely with ancillary and support services. Ability to document clearly. Ability to solve problems. Ability to facilitate groups and implement projects when necessary. Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.
Requirements
- Bachelor’s degree in nursing required.
- Three years of recent clinical nursing experience required.
- Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state.
- Obtains and subsequently maintains required department specific competencies and certifications.
- Advanced communication and interpersonal skills with all levels of internal and external customers.
- Excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills.
- Proficient in organization and planning.
- Strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.
- Working knowledge of quality improvement theory and practice.
- Working knowledge of DRGs and understanding of medical necessity process.
- Knowledgeable of federal, state, and other payers' regulations, requirements, and criteria.
- Adherence to ethical and professional business practices, such as the Association of Clinical Documentation Specialists (ACDIS) code of ethics and official coding guidelines.
- Utilization of appropriate professional documentation to support daily processes, including white papers published by ACDIS, American Health Information Management Association (AHIMA), and other professional organizations.
- Ability to document clearly.
- Ability to solve problems.
- Ability to facilitate groups and implement projects when necessary.
- Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure.
- Recognition of the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.
Nice To Haves
- Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
- Experience in case management, utilization management, and/or coding preferred.
- Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred.
Responsibilities
- Facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients/residents.
- Utilize the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes.
- Provide or coordinate education to all internal customers related to compliance, coding, and clinical documentation issues.
- Act as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis related group (DRG).
- Perform day-to-day evaluation of documentation by the medical staff and healthcare team.
- Gather and analyze information pertinent to documentation findings and outcomes.
- Contribute to a positive working environment.
- Perform other duties as assigned or directed to enhance the overall efforts of the organization.
- Coordinate, facilitate, and negotiate with others.
- Control variances and duplication.
- Work closely with ancillary and support services.
Benefits
- Once off orientation, CDS's can work in office, mostly at home, or Hybrid.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
