Clinical Documentation Sp

SUMMARY:  

The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness.  This involves extensive record review, interaction with physicians, Health Information Management professionals, and nursing staff.   Active participation in team meetings and education of staff in the CDMP® process is a key role.

ESSENTIAL FUNCTIONS:

Job functions reflect the following objectives:

• Ability to learn/develop the skills necessary to perform CDMP®  
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Effective and appropriate communication with physicians
• Timely follow up on all cases especially those with clinical documentation clarifications
• Participate in Task Force Meetings
• Communicates with HIM staff and resolves discrepancies

Accurate input of data into CDMP Trak®  

OTHER RESPONSIBILITIES:

• Manage multiple priorities 
• Performs other duties as assigned.

KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE REQUIRED: 

• Organizational, analytical, writing and interpersonal skills
• Dependable, self directed and pleasant
• Critical thinking, problem solving and deductive reasoning skills
• Recent hospital experience preferably ICU, CCU, or strong Med/Surg. 
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows based software programs
• Knowledge of Medicare Part A 
• Familiar with Medicare Part B  
• General understanding of hospital based Quality initiatives (training provided) 
• Knowledge of regulatory environment
• Understand and support CDMP® documentation strategies (upon completion of training)
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments 

LICENSES AND CERTIFICATIONS: 

• Graduation from a program of nursing, BSN, preferred.
  • Current California Registered Nurse license  
  • Current American Heart Association CPR required.

AGE OF POPULATION SERVED:

 Newborn  Infant/Pediatric  Adolescent  Adult  Geriatric  All    No Patient Care