Clinical Documentation Specialist - CDI Clinical Documentation (Full Time) - 7184

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN. The Clinical Documentation Specialist is an on-site position with primary responsibilities are to ensure that accurate and appropriate physician documentation exists in the patient medical record to support assignment of the most appropriate DRG by the coding staff and to facilitate the accurate representation of the severity of illness and risk of mortality.. The Clinical Documentation Specialist is responsible for extensive medical record review, interaction with physicians, nurse practitioners, physician assistants, and HIM professionals. The Clinical Documentation Specialist will query physicians and other clinicians to facilitate obtaining additional documentation as necessary in the medical record to best describe the most accurate picture of the patient’s condition. The Clinical Documentation Specialist completes chart review for medical necessity and to communicate educational information to the physician regarding clinical documentation improvement matters and the need for accurate and complete documentation in the patient record.

Qualifications

EDUCATION

Graduate of an approved school of nursing (LPN or RN) and/or possess an AAS in HIM from an AHIMA accredited program. RN must have and maintain a current WV licensure. BSN, RN, RHIA, RHIT, CCS, CCDS, CDI-P, or combination thereof, preferred.

EXPERIENCE

A minimum of two years experience in acute care nursing and/or 5 years previous experience as Clinical Documentation Improvement Specialist with CCDS credential.

SKILLS

Ability to use ICD-10 and PCS coding systems, abstract information from charts and apply appropriate DRG. Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills. Working knowledge of inpatient admission criteria. Ability to work independently in a time-oriented environment. Computer literacy and familiarity with the operation of basic office equipment. Assertive personality traits to facilitate ongoing physician communication. Ability to use medical necessity guidelines in relation to the documentation program. Ability to stand and walk in the performance of job responsibilities. Working knowledge of Medicare reimbursement system.