Clinical Documentation Specialist – CDI

Role Overview

• Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.
• Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
• Achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
• Participates in the development and delivery of education for providers and members of the healthcare team.
• Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing or medical field such as MD, DO, NP/APN or PA.
• In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
• Preferred certification or licensure includes: Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS) Certified Documentation Improvement Professional (CDIP).
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills required.
• Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
• Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation.
• Ability to use other software as required to perform the essential functions on the job.
• Experience with databases, spreadsheet software and presentation software preferred.
• Data entry skills and typing skills at minimum 30 wpm.
• Must be comfortable operating independently and in a collaborative environment.

Benefits

• Health insurance
• Flexible work arrangements
• Paid time off
• Professional development