Hybrid RN Clinical Documentation Specialist

Cape Cod Healthcare Inc.; Falmouth (MA); Hybrid; USD 56,000 - 108,000; Part time

Job summary

Cape Cod Healthcare Inc. is seeking a Clinical Documentation Specialist to review medical records and improve physician documentation for accurate severity of illness representation.

The role involves extensive collaboration with physicians, HIM staff, and nursing peers to drive CDMP processes and education. Responsibilities include identifying documentation improvement opportunities, formulating credible queries, and ensuring timely follow-up on all cases.

Qualifications

• Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical; or acute care case management experience within the last four years.
• Knowledge of pathophysiology and disease process
• Knowledge of Medicare Part A and Part B.
• Knowledge of regulatory environment
• Current Massachusetts Registered Nurse license
• Strong interpersonal and negotiation skills with physicians and staff
• Management/supervisory experience preferred
• Must pass JATA exam or equivalent clinical assessment exam

Responsibilities

• Extensive record review and interaction with physicians and HIM professionals.
• Active participation in team meetings and education of staff in the CDMP process.
• Formulate clinically credible queries and timely follow-up on cases.
• Input data into CDMPTrak and support documentation strategies.
• Communicate effectively with physicians and resolve discrepancies.

Skills

Organizational

Analytical

Interpersonal skills

Writing

Dependable

Critical thinking

Problem solving

Deductive reasoning

Education

Bachelor of Science in Nursing

Graduation from a nursing program

Tools

CDMPTrak

Job description

Cape Cod Healthcare Inc. is seeking a Clinical Documentation Specialist to review medical records and improve physician documentation for accurate severity of illness representation.

The role involves extensive collaboration with physicians, HIM staff, and nursing peers to drive CDMP processes and education. Responsibilities include identifying documentation improvement opportunities, formulating credible queries, and ensuring timely follow-up on all cases.