Clinical Documentation Specialist | Full Time | Day

Concord Hospital - Concord, NH

Concord, NH

Hospitals

About the position

The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. The CDS facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation. The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure documentation is a complete and accurate description of services provided to our patients.
• Identifies trends in documentation opportunities and provides education to appropriate audience to ensure compliance with documentation and coding guidelines.
• Reports ongoing issues and improvement plans.
• Utilizes the software system accurately to track and analyze outcomes of documentation improvement efforts, as well as trend the data.
• Assists to develop and maintain clinical documentation improvement policies and procedures.
• Attends all CDIP meetings and educational sessions and is prepared to discuss trends and findings from daily activities.
• Meets all departmental, professional and technical requirements.

Requirements

• Four years of formal training or education in specialty or related specialty beyond the high school level (e.g., Bachelor's Degree).
• RN preferred.
• CDIS/CCDS credential is required upon hire or must be obtained as soon as certification eligibility requirements are met by ACDIS.
• Minimum of 4 years of related experience required.
• Coding knowledge is required.
• Demonstrated ability to work independently and manage time effectively.
• Knowledge of Microsoft software required.