What are the responsibilities and job description for the Clinical Documentation Specialist position at Midland Health?
Job Description
*This position is onsite*
The Registered Nurse (RN) Clinical Documentation Improvement Specialist (CDIS) will facilitate the improvement of clinical documentation in the medical record to reflect an accurate level of care and diagnosis for our patients. The CDIS will obtain and promote the appropriate clinical documentation through interaction with the physicians, nursing staff and Health Information Management (HIM) Coders.
SCHEDULE
Full Time
8:00 AM - 5:00 PM
*This position is onsite*
ESSENTIAL FUNCTIONS
·Provides concurrent review of the clinical documentation in the medical records.· Concurrently queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.· Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately on the DRG worksheet.· Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.· Able to navigate within the electronic healthcare record (EHR) to obtain accurate and complete physician documentation of signs and symptoms, co-morbidities/disabilities, and other pertinent information in regard to level of care and diagnosis of the patient.
EDUCATION AND EXPERIENCE
· Must be a high school graduate or equivalent.· Current State of Texas License as a Registered Nurse.· Minimum of 5 years of clinical experience in an acute care setting· Strong broad-based clinical knowledge and understanding of pathology/physiology.· Knowledge of age-specific needs and the elements of disease processes and related procedures.· Able to convert weights and measures for clinical application.· Ability to analyze collected data to define and address issues.· Excellent written and verbal communication skills and critical thinking skills.
