Description
Provides ongoing education to Clinical Documentation Improvement staff system wide. Provides education and training to newly hired Clinical Documentation Specialists. Collaborates with the Director of CDI in the development of educational materials. Participates in the department quality audit processes by performing assigned audits, communication of findings, and data entry for reporting. Collaborates with Medical Staff Leadership in the ongoing education efforts involving clinical documentation improvement.
Requirements:
5-7 years of experience in acute care as a Clinical Documentation Specialist
Maryland or Compact RN License
ADN Required; BSN preferred
Education
- High School Diploma or GED required and
- Bachelor's degree in Nursing preferred and
- Doctoral degree preferred
- 5-7 years Experience in acute care setting. Experience in working with physicians and clinical professionals. Experience in the clinical documentation specialist role. Experience in documentation review including coding and DRG analysis. required
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- MD - Physician - State Licensure required and
- CCDS - Certified Clinical Documentation Specialist required or
- CDIP - Clinical Documentation Improvement Practitioner required and
- CCS-Certified Coding Specialist preferred
- Knowledge of Maryland rate setting and reimbursement under the CMS waiver a plus.
- Knowledge of inpatient acute care clinical conditions and supporting clinical indicators with appropriate code assignment
- Knowledge of The Joint Commission, HIPAA, ACDIS/AHIMA Query Brief, and other regulatory requirements.
- Basic computer skills including working knowledge of CDI, EHR, and microsoft software applications.
- Excellent interpersonal skills, including verbal and written communications.
- Good public speaking and presentation skills, attention to detail, follow up on outstanding issues, and ability to organize and meet deadlines.
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