RN, Clinical Documentation Specialist (CDI)

Cape Cod Healthcare Inc; Hyannis (MA); On-site; USD 58,000 - 123,000; Part time

Benefits offered by this job

Flexible scheduling

Job summary

Cape Cod Hospital in Hyannis, MA seeks an RN, Clinical Documentation Specialist (CDI) to review medical records and improve documentation for accurate DRG assignments. You will work with physicians, HIM staff and nursing to ensure timely, high-quality CDI input.

The role requires an RN licensed in MA with a BSN preferred and 3+ years CDI experience, plus CDI certification or exam knowledge. 32 hours per week with rotating days. Competitive hourly pay and benefits.

Qualifications

• Graduate of a School of Nursing
• RN licensed in MA (Commonwealth of MA)
• BSN preferred for external applicants
• Minimum 3 years RN CDI practice experience
• CDI certification or exam knowledge
• Knowledge of Medicare Part A & Part B
• Familiarity with regulatory environment
• Strong organizational, analytical, writing & interpersonal skills
• Dependable, self-directed with problem solving

Responsibilities

• Extensive record review and interaction with physicians and staff.
• Participate in team meetings and staff education on CDI.
• Learn and develop CDI duties and input data accurately.
• Identify opportunities to improve documentation and formulate queries.
• Communicate effectively with physicians and HIM staff.
• Follow up on all cases, especially those with queries.
• Participate in task forces and manage multiple priorities.
• Resolve discrepancies with HIM staff and input data into EMR.
• Support clinical documentation strategies and service excellence.

Education

RN license in MA

BSN (preferred)

3+ years CDI RN experience

CDI certification options

Knowledge of Medicare Part A/B

Regulatory knowledge

Interpersonal skills

Job description

Job Description – RN, Clinical Documentation Specialist (CDI) (260817-50000060)

Job Description

RN, Clinical Documentation Specialist – (260817-50000060)

Purpose of Position: The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.

Description

• Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
• Active participation in team meetings and education of staff in the CDI process is a key role.
• Ability to learn/develop the skills necessary to perform CDI duties.
• Accurate and timely record review.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible queries.
• Effective and appropriate communication with physicians.
• Timely follow up on all cases especially those with queries.
• Participate in Task Force meetings.
• Manage multiple priorities.
• Communicates with HIM staff and resolves discrepancies.
• Accurate input of data into the electronic medical record.
• Understand and support clinical documentation strategies.
• Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

Qualifications

RN, Clinical Documentation Specialist – Grade: NSI4, Job Code: 3057

• Graduate of a School of Nursing
• (RN) – Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
• (BSN) – A Bachelor of Science in Nursing (external applicants only)
• Minimum of 3 years of current RN, CDI Practice experience
• Must meet at least one of the following qualifications:
• Certified Clinical Documentation Specialist (CDI)
• CCHC Clinical Documentation Specialist Exam
• Knowledge of Medicare Part A and Part B
• Knowledge of regulatory environment
• Organizational, analytical, writing and interpersonal skills
• Dependable and self-directed
• Critical thinking, problem solving and deductive reasoning skills
• Knowledge of pathophysiology and disease process
• Basic computer skills - familiarity with Windows based software programs
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers

Schedule Details

32 Hours Per Week, Mon-Fri, Rotating Days, 7a-3:30p, Rotating Weekends and Rotating Holidays

Organization

Cape Cod Hospital

Primary Location

Massachusetts-Hyannis

Department

CCH-Care Management

Hourly

Hourly

Hiring Pay Range

$ 42.04 - $ 89.99

The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.