RN, Clinical Documentation Specialist (Per Diem)

Cape Cod Healthcare•Falmouth, MA

About The Position

The RN, Clinical Documentation Specialist performs extensive medical record reviews and works with physicians, Health Information Management (HIM) professionals, and nursing staff to identify and improve clinical documentation. The role includes formulating clinically credible queries, communicating with physicians, following up on cases, resolving documentation discrepancies with HIM staff, and entering data accurately into CDMPTrak®. The specialist supports and communicates CDMP® documentation strategies, participates in team and Task Force meetings, and helps educate staff in the CDMP® process. The position also requires understanding Medicare Part A and Part B guidelines and their impact on DRG assignments. The specialist is expected to provide service consistent with Falmouth Hospital’s CARES values: compassion, accountability, respect, excellence, and service.

Requirements

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

Nice To Haves

Bachelor of Science in Nursing preferred for external applicants only.
Management or supervisory experience preferred.

Responsibilities

Review patient records accurately and in a timely manner.
Recognize opportunities for documentation improvement and formulate clinically credible queries.
Communicate effectively and appropriately with physicians.
Follow up on all cases promptly, especially cases involving queries.
Participate in team meetings and Task Force meetings.
Educate staff about the CDMP® process.
Manage multiple priorities.
Communicate with HIM staff and resolve discrepancies.
Enter data accurately into CDMPTrak®.
Understand, support, and communicate CDMP® documentation strategies.
Understand and communicate differences between Medicare Part A and Part B guidelines and their impact on DRG assignments.
Provide service excellence to patients, family members, visitors, volunteers, and coworkers in keeping with Falmouth Hospital’s CARES commitment.