Clinical Documentation Specialist | Full Time | Day

Concord Hospital; Concord (NH); On-site; USD 70,000 - 95,000; Full time

Job summary

Concord Hospital in Concord, NH seeks a Clinical Documentation Specialist to enhance the quality and compliance of medical record documentation. You will review records, query physicians, and educate care teams on accurate documentation to support hospital resources and patient acuity.

The role requires four years of related experience, RN or equivalent, and CCDS/CDIS certification as applicable. This full-time position emphasizes independent work and collaboration.

Qualifications

• Four years of formal training or education beyond high school (e.g., Bachelor’s Degree).
• RN preferred; CDIS/CCDS credential required or obtained soon after hire.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure documentation is complete and accurate.
• Identifies trends in documentation opportunities and provides education to appropriate audience to ensure compliance with documentation and coding guidelines.
• Reports ongoing issues and improvement plans.
• Utilizes the software system to track and analyze outcomes of documentation improvement efforts.
• Assists to develop and maintain clinical documentation improvement policies and procedures.
• Attends CDIP meetings and educational sessions and discusses trends and findings.

Skills

Attention to detail

Communication

Time management

Education

Bachelor’s Degree

RN preferred

CDIS/CCDS certification

Tools

CDR2/Claro

Job description

Summary The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. The CDS faciliates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation. The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.

Education

• Four years of formal training or education in specialty or related specialty beyond the high school level (e.g., Bachelor’s Degree).
• Certification, Registration & Licensure RN preferred.
• CDIS/CCDS credential is required upon hire or must be obtained as soon as certification eligibility requirements are met by ACDIS.
• CDR2 software through the Claro product knowledge preferred.

Experience

Minimum of 4 years of related experience required. Coding knowledge is required. Demonstrated ability to work independently and manage time effectively. Knowledge of Microsoft software required. CDR2 software through the Claro product knowledge preferred.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure documentation is a complete and accurate description of services provided to our patients.
• Identifies trends in documentation opportunities and provides education to appropriate audience to ensure compliance with documentation and coding guidelines.
• Reports ongoing issues and improvement plans.
• Utilizes the software system accurately to track and analyze outcomes of documentation improvement efforts, as well as trend the data.
• Assists to develop and maintain clinical documentation improvement policies and procedures.
• Attends all CDIP meetings and educational sessions and is prepared to discuss trends and findings from daily activities.
• Meets all departmental, professional and technical requirements.

Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race, color, religion, sex, sexual orientation, gender, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.

Know Your Rights: Workplace Discrimination is Illegal. Applicants to and employees of this company are protected under federal law from discrimination on several bases.

If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, you may contact Human Resources at 603-230-7269.

Physical and Work Requirements

The physical demands and characteristics of the work environment described here are representative of those that will be encountered by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The Dictionary of Occupational Titles Material Handling Classification is SEDENTARY. The employee must regularly lift, carry or push/pull less than 10 pounds, frequently lift, carry or push/pull less than 10 pounds, and occasionally lift, carry or push/pull up to 10 pounds. While performing the duties of this Job, the employee is regularly required to sit. The employee is frequently required to do repetitive motion, hear, and perform activities that require fine motor skills. The employee is occasionally required to bend, climb, kneel, reach, speak, squat, stand, and walk. Specific vision abilities required by this job include color vision, depth perception, far vision, near vision, and peripheral vision. The noise level in the work environment is usually quiet.

Concord Hospital (CH) is a nationally-accredited, progressive regional health system. Over the past two decades, CH has evolved from a community hospital to a $550 million net revenue regional integrated health system with more than 4,700 employees, leaders and clinicians who are talented, mutually supportive, and community centered in helping the organization meet its community mission. CH has sophisticated clinical and management practices. The organization consistently performs among the top ten percent of national organizations and has received many national accolades (e.g., most wired, Press Ganey's summit award).