Job Summary : The Clinical Documentation Specialist (CDS) is responsible for improving the overall quality and completeness of clinical documentation in the medical records to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients.
This position involves concurrent medical record review as well as education and interaction with physicians, HIM Coders and others involved in the care of the patient.
Minimum Requirements : Registered Nurse with current Pennsylvania Licensure
Minimum of five years of recent advanced clinical experience and extensive knowledge of complex disease processes in an acute care hospital setting.
Must have strong communication, teaching, and presentation skills; must be detailed oriented, possess good problem solving skills.
Demonstrated knowledge of medical terminology, anatomy and physiology
Ability to establish and maintain strong verbal and written communication with providers and other clinicians. Essential technical / motor skills : requires excellent observation skills, analytical thinking, problem solving, and excellent verbal and written communication.
Preferred Qualifications : Registered Nurse with CCDS or CDIP, CPC
At least 1-2 years experience in an acute hospital setting functioning in a clinical documentation role or coding role. Experience assigning Working DRGs based on coding guidelines / regulations issued by AHA, AHIMA, and CMS.
Licensure and Certifications : CCDS or CDIP certification preferred upon hire; mandatory within 1-2 years of employment.
PA RN Licensure;Ability to work independently;License in related field required;Strong communication skills
CPC CCS-P and / or RHIT preferred;CCDS or CDIP