Clinical Documentation Specialist

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<p><strong>Job Responsibilities:</strong> </p><ul><li>Manages assignments and projects as assigned. </li><li>Participates in the daily operations and activities of the Clinical Documentation Improvement (CDI) program to continually enhance documentation. </li><li>Utilizes most current documentation tools available. </li><li>Regularly and effectively communicates with clinical staff. </li><li>Collaborates with coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards. </li><li>Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of compliant physician queries, when appropriate. </li><li>Facilitates communication of various professionals to support organizational goals related to documentation integrity, compliance, quality and coding. </li><li>Assists in development and delivery of education for both clinical and non-clinical staff. </li><li>Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively. </li><li>Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices. </li><li>Participates in the training of new employees as needed. </li><li>Ensures that work is completed accurately and according to schedule. </li></ul><p><strong>Minimum Qualifications:</strong> </p><p>Current registered nurse (RN) license with a Bachelor's Degree in Nursing plus 2 years of experience in acute care, health care administration or commensurate experience.</p><p>Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) credential must be obtained within one year of hire. Experience with ICD-10-CM/PCS coding and DRG assignment. Outstanding oral, written and interpersonal skills. Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement. </p><p><strong>Preferred Qualifications:</strong> </p><p>CCDS or CDIP upon hire plus 2 years of clinical documentation improvement experience</p>

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