RN, Clinical Documentation Specialist (Per Diem)

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

Purpose of Position

The Clinical Documentation Specialist 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 CDMP® process is a key role.
• Ability to learn/develop the skills necessary to perform CDMP®
• 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 CDMPTrak®
• Understand and support CDMP® documentation strategies
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Falmouth Hospital’s commitment to CARES: compassion, accountability, respect, excellence and service.

Qualifications

• Organizational, analytical, writing and interpersonal skills
• Dependable and self directed.
• Critical thinking, problem solving and deductive reasoning skills
• Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical; or acute care case management experience within the last four (4) years.
• Knowledge of pathophysiology and disease process
• Basic computer skills – familiarity with Windows based software programs
• Knowledge of Medicare Part A and Part B.
• Knowledge of regulatory environment
• Graduation from a program of nursing
• Bachelor of Science in Nursing preferred (external applicants only)
• Current Massachusetts Registered Nurse license
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
• Management/supervisory experience preferred
• Must successfully pass the JATA exam or equivalent clinical assessment exam.

Schedule Details

Per Diem, Rotating Days, Shift: 7 AM - 3:30 PM (Hybrid)

Organization

Falmouth Hospital Association

Primary Location

Massachusetts-Falmouth

Department

FHA-Care Management

Annual/Hourly

Hourly

Hiring Pay Range

40.71 - 78.2