Clinical Documentation Specialist

SUMMARY

The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.

STATUS: Full time

LOCATION: Riedman Campus

DEPARTMENT: Clinical Documentation

SCHEDULE: Monday - Friday days

ATTRIBUTES

• 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.
• Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.
• Previous CDS experience preferred
• RN, PA, NP, MBBS or MD prepared candidates.
• Must obtain CCDS certification within 30 months of hire.

RESPONSIBILITIES

• Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety
• Effective and appropriate communication with physicians
• Provides education to members of the patient care team regarding the CDS process.
• Timely follow up on all cases and resolution of those with clinical documentation clarifications

EDUCATION:

• AS: Nursing (Required)

PHYSICAL REQUIREMENTS: S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

LICENSES/CERTIFICATIONS:

• RN - Registered Nurse - New York State Education Department (NYSED)
• BLS - Basic Life Support - American Heart Association (AHA)

PAY RANGE: $78,000.00 - $95,000.00