Clinical Documentation Specialist II

This position may qualify for a sign-on bonus

The Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all

selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Serves as a department educator for other specialists and as a senior team leader in the department. Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Intermediate level position for experienced CDS. Demonstrates all skills of CDS I with <5% error rate. Completes established competencies for the position within designated introductory period. Other related duties as assigned.

MINIMUM EDUCATION: Graduate of an accredited school of Nursing, AHIMA accredited school, United States or International School of Medicine

PREFERRED EDUCATION: Bachelor’s Degree in Health Information Management and/or Nursing or other Healthcare related field.

MINIMUM EXPERIENCE: 2-5 years of CDS experience in acute care setting

PREFERRED EXPERIENCE: 6 or more years of experience in acute care setting

REQUIRED CERTIFICATIONS/LICENSURE: RHIA, RHIT, CCS, Certified Clinical Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN. MD, DO, PA, NP.

PREFERRED CERTIFICATIONS/LICENSURE: NA

REQUIRED COURSES/ COMPLETIONS (e.g., CPR): NA
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