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CDI Clinical Documentation Specialist

Location : Columbia, SC
Job Type : Direct
Hours : Full Time
Travel : No
Relocation : No
Job Industry : Healthcare - Health Services
Job Category : Nursing

Job Description :

CDI Clinical Documentation Specialist


Job Description for the CDI Clinical Documentation Specialist
Position Summary: The CDI Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.  Through concurrent interaction with physicians, case managers, coders, other health care team members and scheduled review of the patient’s medical record, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients.  Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.  The CDI Clinical Documentation Specialist will actively participate in educating appropriate hospital and medical staff about the changes associated with transitioning to ICD-10. Follows Providence Hospitals' Mission, Vision, and Values.
JOB REQUIREMENTS for the CDI Clinical Documentation Specialist
 Qualifications/Specifications for the CDI Clinical Documentation Specialist
Education:  Bachelor’s degree (BS, BSN, BS-HIM), Masters preferred.  
Licensure/Certification:  Licensed Registered Nurse (RN), Registered Health Information Management Administrator (RHIA), Registered Health Information Management Technician (RHIT), Clinical Coding Specialist (CCS)or combination thereof preferred
Professional Experience:  The CDI Clinical Documentation Specialist must have prior experience in inpatient coding, clinical documentation improvement, and/or case management preferred. Minimum of five years’ experience in a clinical role and a minimum of two years’ experience with inpatient coding, process improvement in an acute care facility preferred or equivalent experience.  Coding skills with experience in ICD-10-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinics. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified or Certified Documentation Improvement CDI Practitioner credential preferred. Excellent oral, written and communication skills. Current working knowledge of one or more of the following: Cardiac Thoracic Surgery, Medical / General Surgical, Critical Care, Care Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Quality Measures, Hospital Acquired Conditions and Public Reporting of Hospital Quality Data. Experience in development of reference based continuing educational programs using Adult Learning Principles


Required Qualifications :
 
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