RN Clinical Documentation Specialist

2300 Montefiore Nyack Hospital; Joliet (IL); On-site; USD 73,012 - 81,278; Full time

Job summary

2300 Montefiore Nyack Hospital is looking for a Clinical Documentation Specialist responsible for improving inpatient medical record documentation by educating and interacting with physicians and staff. A strong foundation in med/surg clinical experience is preferred, along with the ability to perform documentation audits and develop improvement processes.

The role requires excellent communication, analytical skills, and attention to detail, along with knowledge of EPIC and 3M. A BSN and CCDS certification are preferred for candidates.

Qualifications

• Current CDI experience with strong med/surg clinical experience.
• Ability to work independently with minimal supervision.
• Must possess clear communication and interpersonal skills.

Responsibilities

• Facilitate improvement of inpatient medical record documentation.
• Conduct audits and reviews of inpatient documentation.
• Develop processes for documentation improvement.

Skills

Interpersonal skills

Analytical skills

Attention to detail

Critical thinking

Computer skills (Excel, Word, PowerPoint)

Education

BSN Preferred

CCDS Certification preferred

Registered Nurse - New York State

Tools

EPIC

3M

Job description

Job Details

City/State: Nyack, New York

Department: Clinical Documentation Improvement

Work Shift: Day

Work Days: Alternate Weekends, Alternate Work Schedule, Days Vary, Per Diem

Scheduled Hours: 10 AM-6 PM (8 Hours per day)

Pay Rate/Range: $53.00-$59.00 per hour

Job Summary

Responsible for facilitating improvement of inpatient medical record documentation by intervening, interacting with, and educating physicians and other licensed independent practitioners. Clinical Documentation Specialists will review the documentation and coding sequence for impact on potential denials, patient safety indicators/quality, hospital acquired conditions, and the mortality index.

Essential Functions

• Performs inpatient documentation audit and review.
• Develops processes to identify opportunities for documentation improvement, intervenes with attending physicians, and facilitates improvement in electronic medical record documentation (EPIC).
• Interacts with medical staff and others regarding documentation improvement.
• Conducts one‑to‑one teaching for physicians and educates physicians/practitioners regarding documentation and its effects.
• Initiates and maintains records and databases to quantify impact of interventions and ensure follow‑through of recommendations.
• Identifies, investigates and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation, including second‑level reviews as needed.
• Coordinates clinical information from various sources and databases to develop recommendations for documentation.
• Educates department personnel from individual expertise and experience.

Qualifications

• BSN Preferred.
• Current CDI experience in conjunction with strong med/surg clinical experience.
• Working experience with Quality, HIM, Infection Control, Physicians.
• Clear interpersonal and communication skills.
• Analytical skills to interpret medical record documentation and departmental metrics.
• Self‑motivated individual with critical thinking skills.
• Ability to work independently with minimal supervision.
• Computer knowledge of Excel, Word and PowerPoint required.
• Must be detail oriented.
• Knowledge of 3M and EPIC.
• CCDS – Certified Clinical Documentation Specialist – Association of Clinical Documentation Integrity Specialists (ACDIS) Preferred.
• Registered Nurse – New York State Board of Nursing required.

Eligibility and Equal Opportunity Statement

Montefiore Nyack Hospital is an equal employment opportunity employer. Montefiore Nyack Hospital will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.