Summary:# The Clinical Documentation Specialist (CDS) II conducts concurrent, comprehensive reviews of clinical documentation within the medical record to achieve accurate and detailed documentation. The CDS will regularly communicate with providers for clarification of documentation through querying.
The CDS will also be responsible for educating providers about the program and how to improve their documentation through daily conversations as well as formal classroom presentations. Education: Must either have a Registered Nurse (RN) license, medical license, or license in a related field. US or Medical Graduates; Nurses Licensure:## Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Practitioner (CDIP). Certified Coding Specialist (CCS) is a plus.
Experience:### # Minimum of 2 years of experience in practical CDI work Skills and Abilities: Must display teamwork and commitment while performing daily duties Must demonstrate initiative and discipline in time management and medical record review Recognize opportunities for documentation improvement Strong Verbal Communications Skills Strong Written Communications Skills Excellent Interpersonal Skills Computer skills: Excel, PowerPoint, MS Word - Intermediate Level Excellent Organizational Skills Demonstrates knowledge of Official Coding Guidelines and the DRG Classification System to insure compliance with such regulations as they relate to the CDI function Excellent organizational skills for initiation and maintenance of efficient workflow Knowledge of coding compliance and regulatory standards Understand pathophysiology of disease processes and their management. Demonstrate knowledge of and perform the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS).
St Joseph School Of Nursing