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CLINICAL DOCUMENTATION SPECIAL

Cape Cod Healthcare


Location:
Falmouth, MA
Date:
04/19/2018
2018-04-192018-05-19
Job Code:
180104-50006935
Categories:
  • Healthcare
Cape Cod Healthcare
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Job Details


CLINICAL DOCUMENTATION SPECIAL-180104-50006935
Description
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians clinical documentation
  • Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
  • Active participation in team meetings and education of staff in the CDMP process is a key role.
  • Ability to learn/develop the skills necessary to perform CDMP
  • Accurate and timely record review.
  • Recognize opportunities for documentation improvement.
  • Formulate clinically credible queries.
  • Effective and appropriate communication with physicians.
  • Timely follow up on all cases especially those with queries.
  • Participate in Task Force meetings.
  • Manage multiple priorities.
  • Communicates with HIM staff and resolves discrepancies.
  • Accurate input of data into CDMPTrak.
  • Understand and support CDMP documentation strategies.
  • Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

Qualifications:
 
  • Organizational, analytical, writing, and interpersonal skills
  • Dependable and self directed,
  • Critical thinking, problem solving, and deductive reasoning skills.
  • Recent acute care experience required preferably ICU, CCU, or strong Medical/Surgical; or acute care case management experience within the last four (4) years.
  • Knowledge of pathophysiology and disease process.
  • Basic computer skills - familiarity with Windows based software programs.
  • Knowledge of Medicare Part A and Part B.
  • Knowledge of regulatory environment.
  • Graduation from a program of nursing.
  • Bachelor of Science in Nursing preferred (external applicants only).
  • Current Massachusetts Registered Nurse license.
  • Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers.
  • Management/supervisory experience preferred.
  • Must successfully pass the JATA exam or equivalent clinical assessment exam.

Schedule Details: Per diem hours, rotating days, occ weekends, occ holidays
Organization: Falmouth Hospital Association
Primary Location: Falmouth
Department: FHA-Care Management
Employee Classification: Regular-Regular
Shift: Day
Weekend Shifts: Occasional
Holiday Shifts: Occasional
Posting Start Date: Jan 25, 2018
Posting End Date: Ongoing
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