The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of the medical record to ensure appropriate clinical documentation through engaging physicians, nursing staff, ancillary departments, and coding staff in a collaborative manner in order to ensure quality of care, and appropriate and accurate reimbursement based on severity of illness, risk of mortality and level of services provided to patients. Utilizes strong clinical knowledge, official coding guidelines, and standards of compliance to identify clinical documentation opportunities and to achieve results.

Minimum Qualifications:

Education - Bachelor's Degree in healthcare related field (Required), BSN Preferred, Master's Degree (Preferred)

Experience - Three-Five (3-5) years of nursing practice, physician practice/education, care management, utilization review or quality resource experience in an acute care setting. Medical and coding experience a plus.

Licensure/Certification - Registered Professional Nurse (compact) if applicable. Certification as a Clinical Documentation Specialist (CDIS) or Clinical Documentation Improvement Practitioner (CDIP) required

Knowledge/Skills/Abilities -Excellent interpersonal skills

• Knowledge of, but not limited to, current coding guidelines and methodologies, MS-DRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions.

• Demonstrate extensive clinical knowledge necessary to meet performance standards in the position and provide clinical documentation guidance to peers and providers

• Highly effective verbal and written skills are required to work successfully with a diverse group of staff at various levels within the organization.

• Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)

• Demonstrates critical thinking skills, able to assess, evaluate, and teach.

• Self-motivated and able to work independently without close supervision. Strong communication skills (interpersonal, verbal and written)

• Ability to work independently and think creatively

• Must be able to work flexible hours which may include weekends as required to meet business needs.

• Familiarity with the external reporting aspects of healthcare

• Familiarity with the business aspects of healthcare, including Maryland payment systems

Experience

• Certification as a Clinical Documentation Specialist (CDIS) OR Clinical Documentation Improvement Practitioner (CDIP)
• 3 year(s): Nursing practice, physician practice/education, care management, utilization review or quality resource experience in an acute care setting.

• 1 year(s): Medical and coding experience