Clinical Documentation Specialist

AdventHealth - Shawnee, KS

Full-time - Mid Level

Shawnee, KS

Hospitals

About the position

The Clinical Documentation Specialist (CDS) at AdventHealth Shawnee Mission plays a crucial role in ensuring the accuracy and integrity of clinical documentation. This position involves collaborating with healthcare providers to support appropriate clinical representation and severity levels for patients, thereby enhancing the quality of care provided. The CDS also works closely with coding staff to clarify documentation and improve overall documentation practices within the hospital.

Responsibilities

• Assist physicians and healthcare providers in accurate clinical documentation.
• Facilitate modifications to clinical documentation to reflect the appropriate clinical picture and severity of illness.
• Collaborate with HIM inpatient coding staff to clarify documentation for accurate MSDRG assignment.
• Identify opportunities to improve the integrity of healthcare documentation as part of the care team.
• Utilize CDI software to document work products consistent with departmental goals.
• Analyze data and develop reports to identify opportunities for improvement in documentation processes.

Requirements

• Kansas Registered Nurse License
• Associate's Degree; Bachelor's Degree preferred
• 1 to 2 years of position-related experience
• RN clinical experience

Benefits

• Vision, Medical & Dental Benefits from Day One
• Student Loan Repayment Program