Job Description

The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record. The CDS facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation. The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served. Education required includes four years of formal training or education in specialty or related specialty beyond the high school level (e.g., Bachelor’s Degree). RN preferred. CDIS/CCDS credential must be obtained as soon as certification eligibility requirements are met by ACDIS. Minimum of 4 years of related experience required. Coding knowledge is required. Demonstrated ability to work independently and manage time effectively. Knowledge of Microsoft software required. Responsibilities include impacting productivity and quality goals for clinical documentation improvement program, demonstrating knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines, obtaining needed clarification of clinical documentation, identifying trends in documentation opportunities and providing education, reporting ongoing issues and improvement plans, utilizing software systems to track and analyze outcomes, assisting to develop and maintain clinical documentation improvement policies and procedures, attending all CDIP meetings and educational sessions, and meeting all departmental, professional and technical requirements. Physical and work requirements include sedentary classification with occasional lifting up to 10 pounds, frequent sitting, repetitive motion, hearing, fine motor skills, occasional bending, climbing, kneeling, reaching, speaking, squatting, standing, and walking. The noise level is usually quiet. Concord Hospital is an Equal Employment Opportunity employer.

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