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

St. Mary's Medical Center Inc; Huntington (WV); On-site; USD 85,000 - 100,000; Full time

Job summary

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN for an on-site role to ensure accurate documentation in patient records to support DRG assignments and proper severity representation.

You will review charts, query clinicians, and educate staff on CDI matters to improve documentation quality. Requirements include RN with WV licensure, AAS in HIM, and 2+ years acute care nursing experience or 5 years as a CDI with CCDS credential.

Qualifications

• Graduate of an approved nursing program (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.
• A minimum of two years experience in acute care nursing and/or 5 years previous experience as Clinical Documentation Improvement Specialist with CCDS credential.
• 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.
• Strong clinical knowledge and pathology/physiology; excellent written and verbal communication; critical thinking.
• Knowledge of inpatient admission criteria; ability to work independently; computer literacy; familiarity with Medicare reimbursement.

Responsibilities

• Review medical records to ensure accurate documentation supporting DRG assignment.
• Query physicians and clinicians to obtain clarifications or additional documentation.
• Educate physicians on clinical documentation improvement matters and documentation standards.
• Communicate findings to coding staff and HIM professionals to ensure accurate patient representation.

Skills

ICD-10/PCS coding

Chart abstraction

DRG assignment

Medical record review

Clinical communication

Critical thinking

Inpatient criteria knowledge

Independence in time management

Computer literacy

Medicare knowledge

Education

RN with WV licensure

AAS in HIM

BSN/RHIA/RHIT/CCDS/CDI-P preferred

Tools

AHIMA accredited program

Job description

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

#16330

Job Description

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.

Requirements

EDUCATION:

Graduate of an approved school of nursing (LPN or RN) and/or possess an AAS in HIM from anAHIMA 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.

This Company is an Equal Opportunity Employer, and does not discriminate on the basis of race, gender, ethnicity, religion, national origin, age, disability, veteran status, or on any other basis prohibited by law. Information on race, gender and national origin will only be used for statistical and recordkeeping purposes, and will not be used in making any employment decisions. All information provided will be kept separate from your expression of interest. Providing this information is strictly voluntary, and you will not be subjected to any adverse action or treatment if you choose not to provide this information. If you do not choose to answer these questions, we ask that you select "Decline to Identify" for each question. Thank you for your voluntary cooperation.