Clinical Documentation Specialist II

Clinical Documentation Specialist II

Requirements

• Bachelor’s degree in healthcare related field.
• Registered Nurse (RN) in the state of Ohio preferred.
• Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS must be obtained within 1 year of hire.
• A minimum of two years of experience as inpatient or outpatient CDIS I required.
• Proficient in the use of department CDI software and able to utilize the reporting functions as needed to develop materials for meetings and presentations, as requested by CDI leadership.

Responsibilities

• Performs review of inpatient or outpatient EHR and query process according to department guidelines.
• Maintains an accurate record of EHR review and query activity in the CDI software system.
• Collaborates with CDI leadership to develop and present educational materials for peers as well as clinical team.
• Represents the department at institute, division or hospital department meetings upon request of CDI leadership.
• Acts as peer mentor for new CDI staff and as a resource for inpatient or outpatient CDIS I caregivers.
• Meets or exceeds daily reviews, query and query response targets.
• Assists co-caregivers as workload requires.
• Works with department leadership on special projects and performance improvement initiatives.
• Identifies trends and opportunities for improvement in inpatient or outpatient clinical documentation.
• Ensures effective communication with physicians and other clinical staff.
• Conducts second level reviews as part of the process improvement initiatives.
• Leads department teams and committees as assigned by leadership.
• Facilitates and participates in caregiver engagement activities.
• Facilitates and participates in department sponsored educational opportunities.
• Meets hospital specific educational requirements.
• Demonstrates continued advancement in professional growth: Takes responsibility for own learning through reading professional journals and attending webinars/seminars.
• Encouraged to advance formal education and work toward ACDIS certification.
• Completes required CEUs to maintain professional licensure and certification.
• Other duties as assigned.

Preferred Qualifications

• Knowledge of physician documentation in the inpatient or outpatient setting preferred.
• Knowledge of inpatient or outpatient payment methodologies preferred.