- Conducts thorough medical record reviews using CDI software integrated with EMR
- Facilitates documentation enhancement by engaging in committee meetings
- Supports the coordination of clinical documentation improvement in line with corporate compliance guidelines and financial reimbursement standards
- Delivers education to providers, nurses, and other CDI staff
- Understanding of federal and state regulations
- Ensuring clinical documentation integrity to support medical necessity, diagnosis- related groups (DRG), and quality of care
- Capability to work independently, prioritize tasks, and effectively identify and resolve issues
- Ability to establish and maintain collaborative relationships with various disciplines
- Licensed RN or equivalent, or higher education in a healthcare-related field
- Minimum 5 years of inpatient clinical experience in an acute hospital setting, with a preference for critical care experience
- Extensive knowledge of complex disease processes
- Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Practitioner (CDIP) certification within three years of starting the role
- Experience with Epic software is advantageous
- Proficient in computer usage, spreadsheets, and Microsoft Office
- BS in Nursing preferred (or achieved within 5 years of employment) OR a graduate of another health-related field
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Clinical Documentation Specialist - Canandaigua, United States - Thompson Health
Description
Clinical Documentation Specialist (CDS Nurse)
Are you an RN with at least 5 years of recent inpatient clinical experience? Are you looking to advance your career in a different direction? The role of Clinical Documentation Specialist Nurse might be just what you need! Join the Thompson Team.
Remote or In-person, Per Diem Position (must be available for occasional on-site visits)
Job Responsibilities:
Essential Job Specific Competencies:
Qualifications/Experience:
Education:
Company Culture:
Thompson Health promotes a culture of empowerment. At Thompson, interdisciplinary teams collaborate to enhance care, where your input is valued and your suggestions are integral to finding solutions. With three executives having an RN background, we recognize the significance of the patient experience. Immerse yourself in an environment that supports your development, appreciates your contributions, and celebrates your achievements.
Position Pay Range: $ /hour
Starting Pay: Commensurate with experience
Thompson Health is an EOE advocating for women, minorities, individuals with disabilities, and veterans to consider applying
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.