At Valley Forge Medical Center, an addiction hospital, we help our patients live better, healthier lives by providing specialized care in Hospital level addiction treatment. We also help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members.

Job Description:

The Clinical Documentation Specialist (CDS) at Valley Forge Medical Center facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation. This role involves extensive interaction with physicians, nursing staff, Counselors, and the Health Information Management Department coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. The CDS also educates all members of the patient care team on documentation guidelines on an ongoing basis.

Responsibilities:

- Facilitate appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.

- Perform admission reviews for specific patient populations using clinical documentation guidelines.

- Assist in the medical screening process by documenting the appropriateness of patient admission.

- Review all physician and clinical documentation, lab results, diagnostic information, and treatment plans.

- Identify documentation opportunities that reflect the severity of illness, acuity, and resource consumption.

- Communicate with physicians to ensure documentation opportunities are clarified.

- Update DRG worksheet to reflect any changes in patient status, procedures/treatments, and confer with physicians to finalize diagnoses.

- Conduct follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in the patient's chart.

- Collaborate with coding staff to determine appropriate DRG and required documentation.

- Stay current with and conduct ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, and nursing and allied health professionals.

- Screen admissions to determine the necessity and appropriateness of hospitalizations using facility criteria.

- Recommend admission or observation disposition to the ED physician in accordance to the screening.

- Attend and participate in Multidisciplinary Rounds (MDR) of the designated/assigned unit.

Qualifications:

- Graduation from a bachelor's level program of Nursing (or commitment to obtain within 2 years of hire).

- Minimum of 5 or more years of recent clinical experience, preferably in Medical/ Critical Care, Intensive Care, or Emergency Room Care.

- Ability to interact well with physicians and other teams, including HIM coders.

- Computer literate with working knowledge of Google and/or Microsoft-based software programs/applications.

- Excellent communication, organizational, analytical, writing, and interpersonal skills.

- Dependable, self-directed, and pleasant.

- Critical thinking, problem-solving, and deductive reasoning skills.

- Recent hospital experience.

- Knowledge of Pathophysiology and Disease Process, Medicare Part A and B, and regulatory environment.

- Understand and support CDMP documentation strategies.

Licenses and Certifications:

- Current Registered Nurse license.

- Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.

Schedule: 

M-F

9am-5pm