Purpose of Position:
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.
Description:
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Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
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Active participation in team meetings and education of staff in the CDI process is a key role.
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Ability to learn/develop the skills necessary to perform CDI duties.
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Accurate and timely record review.
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Recognize opportunities for documentation improvement.
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Formulate clinically credible queries.
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Effective and appropriate communication with physicians.
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Timely follow up on all cases especially those with queries.
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Participate in Task Force meetings.
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Manage multiple priorities.
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Communicates with HIM staff and resolves discrepancies.
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Accurate input of data into the electronic medical record.
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Understand and support clinical documentation strategies.
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Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
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Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.
Qualifications:
RN, Clinical Documentation Specialist – Grade: NSI4, Job Code: 3057
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Graduate of a School of Nursing
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(RN) - Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
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(BSN) – A Bachelor of Science in Nursing (external applicants only)
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Minimum of 3 years of current RN, CDI Practice experience
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Must meet at least one of the following qualifications:
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Certified Clinical Documentation Specialist (CDI)
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CCHC Clinical Documentation Specialist Exam
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Knowledge of Medicare Part A and Part B
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Knowledge of regulatory environment
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Organizational, analytical, writing and interpersonal skills
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Dependable and self-directed
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Critical thinking, problem solving and deductive reasoning skills
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Knowledge of pathophysiology and disease process
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Basic computer skills – familiarity with Windows based software programs
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Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
Schedule Details:
40 Hours Per Week, Mon-Fri, Rotating Days, 7a-3:30p, Rotating Weekends and Rotating Holidays
Organization: Cape Cod Hospital
Primary Location: Massachusetts-Hyannis
Department: CCH-Care Management
Annual/Hourly: Hourly
Hiring Pay Range: $42.04 - $89.99
