Clinical Docmt Specialist (RN) - Full-time / Part-time

Clinical Documentation Specialist (CDS) serves as a liaison for Case Management, working closely with the medical staff, nursing staff and Coding Staff in support of excellence in patient information documented in the medical record. The primary purpose of this role is to ensure that all diagnoses, care, and treatment are documented in support of patient care and accurate DRG assignment. Improves coding specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided. This includes medical necessity, capturing complications/comorbidities during the patient's stay. The CDS is accountable for concurrent review of medical records to track documentation supporting the severity of the illness and the resources utilized. A concentrated effort is put forth on patients concurrently with diagnosis which have the potential to be in the population of core measure assignment for quality of care review. The CDS assists in the development of educational resources necessary to assure compliance with federal, state, and private rules and regulations on data collection, coding, and reimbursement. The CDS also provides a mechanism and guidelines to assure documentation of pertinent clinical findings in the medical record and clarifies ambiguous documentation by the physician. The CDS helps to meet the Medicare Conditions of Participation requirement that "medical records contain complete information/documentation regarding evaluations, interventions, care provided, services , care plans, discharge plans, and the patient's response to those activities." T he CDS also helps to meet the JCAHO standard IM 6.10 which states: "the medical record contains sufficient information to identify the patient, support the diagnosis/condition, justify the care, treatment and services; document the course and results of care, treatment and services; and promote continuity of care among providers." Must possess a current, valid RN or LPN license or an RHIA, RHIT, or CCS credential.

This position requires a minimum of three-five years coding experience in an acute care setting; requires extensive knowledge ICD-9-CM and CPT principles and guidelines; extensive knowledge of reimbursement systems, Medicare, Federal, State and Local payer rules and regulations; strong leadership and interpersonal skills in oral and written communications; knowledge of coding and abstracting systems and encoders; and proficiency in use of Microsoft Office Word and Excel.