RN, Clinical Documentation Specialist
About The Position
The RN, Clinical Documentation Specialist plays a key role in reviewing medical records, interacting with physicians, HIM professionals, and nursing staff. This position involves active participation in team meetings and educating staff on the Clinical Documentation Improvement (CDI) process. The specialist must be able to learn and develop the necessary skills for CDI duties, ensuring accurate and timely record review, identifying opportunities for documentation improvement, and formulating clinically credible queries. Effective communication with physicians, timely follow-up on cases, and participation in Task Force meetings are essential. The role also requires managing multiple priorities, communicating with HIM staff to resolve discrepancies, and accurately inputting data into the electronic medical record. Understanding and supporting clinical documentation strategies, providing service excellence, and comprehending the differences between Medicare Part A and Part B guidelines and their impact on DRG assignments are also crucial aspects of this position.
Requirements
- Graduate of a School of Nursing (RN)
- Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
- Minimum of 3 years of current RN, CDI Practice experience
- Must meet at least one of the following qualifications: Certified Clinical Documentation Specialist (CDIS) or CCHC Clinical Documentation Specialist Exam
- Knowledge of Medicare Part A and Part B
- Knowledge of regulatory environment
- Organizational, analytical, writing and interpersonal skills
- Dependable and self-directed
- Critical thinking, problem solving and deductive reasoning skills
- Knowledge of pathophysiology and disease process
- Basic computer skills – familiarity with Windows based software programs
- Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
Nice To Haves
- BSN – A Bachelor of Science in Nursing (external applicants only)
Responsibilities
- Extensive record review
- Interaction with physicians, HIM professionals, and nursing staff
- Active participation in team meetings
- Education of staff in the CDI 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 the electronic medical record
- Understand and support clinical documentation strategies
- Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers
- Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
