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CLINICAL DOCUMENTATION SPECIAL

Cape Cod Healthcare


Location:
Hyannis, MA
Date:
04/19/2018
2018-04-192018-05-19
Job Code:
180104-50006931
Categories:
  • Healthcare
Cape Cod Healthcare
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Job Details


CLINICAL DOCUMENTATION SPECIAL-180104-50006931
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

  • Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Hospital’s commitment to CARES: compassion, accountability, respect, excellence and service.

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 4 years recent (within the past 4 years) Case Management experience.
  • 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 required 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
  • ***Certified Clinical Documentation Specialist or JATA Competency Exam.***

Schedule Details: Per diem hours between 7a - 11:30p
Organization: Cape Cod Hospital
Primary Location: Hyannis
Department: CCH-Care Management
Employee Classification: Regular-Per Diem
Shift: Day/Eve
Weekend Shifts: Occasional
Holiday Shifts: Occasional
Posting Start Date: Jan 4, 2018
Posting End Date: Ongoing
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