Clinical Documentation Specialist Job at Heritage Valley Health System
Department: Clinical Documentation Specialists.
Work Hours: Primarily Monday thru Friday, daylight.
The CDS facilitates accurate documentation for severity of illness and quality in the medical record. The CDS reviews medical records for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Must function independently with excellent attention to detail and be able to multi-task and receive information from multiple sources while continually establishing priorities. Active participation in team meetings and education of staff in the CDMP.
Requirements
Graduate of an accredited bachelors in nursing program, current active nursing license in Pennsylvania and a minimum of five years acute care experience in med/surg, critical care, emergency room, or PACU. Knowledge of Pathophysiology and Disease Process. Knowledge of regulatory environment. Must possess critical thinking, problem solving and excellent interpersonal skills. Must be able to effectively and appropriately communicate with physicians & coding professionals. Basic IT skills required; familiarity with Windows based software programs.
Successful completion of Acts 73 and/or 169 clearances within 90 days of commencing employment, if applicable.
Preferred
Bachelor Degree in Nursing. Knowledge of Medicare Part A and Part B. Knowledge of Core Measures and Patient Safety Indicators.
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