RN, Clinical Documentation Specialist (Per Diem)

Cape Cod Healthcare Inc; Falmouth (MA); On-site; USD 116,651,000 - 224,075,000; Full time

Job summary

Falmouth Hospital Association in Massachusetts is seeking a Clinical Documentation Specialist to review medical records and improve the accuracy of severity of illness documentation. The role emphasizes collaboration with physicians, HIM and nursing staff, and ongoing education of the CDMP process.

The candidate should have a nursing degree, MA RN license, acute-care experience, and familiarity with Medicare guidelines; the position may require managing multiple priorities and performing timely

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
• 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.

Responsibilities

• 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

Skills

Organizational skills

Analytical skills

Interpersonal skills

Critical thinking

Problem solving

Deductive reasoning

Written communication

Self-directed

Dependable

Negotiation skills

Management experience

Physician communication

Education

Bachelor of Science in Nursing

Massachusetts RN license

Tools

CDMPTrak®

Job description

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.

Thepayrange 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.

Description

• 1. Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
• 2. Active participation in team meetings and education of staff in the CDMP® process is a key role.
• 3. Ability to learn/develop the skills necessary to perform CDMP®
• 4. Accurate and timely record review
• 5. Recognize opportunities for documentation improvement
• 6. Formulate clinically credible queries
• 7. Effective and appropriate communication with physicians
• 8. Timely follow up on all cases especially those with queries
• 9. Participate in Task Force meetings
• 10. Manage multiple priorities
• 11. Communicates with HIM staff and resolves discrepancies
• 12. Accurate input of data into CDMPTrak®
• 13. Understand and support CDMP® documentation strategies
• 14. 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.

Organization

Falmouth Hospital Association

Primary Location

Massachusetts-Falmouth

Department : FHA-Care Management

Annual/Hourly : Hourly

Hiring Pay Range : $ 40.71 - $ 78.2