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ID# 001883


All Med Search
Providence, RI .
United States
858-229-5939 (Main Phone)
Manages Others
Experience Required
Degree Required
Security Clearance Required
Employment Type
Work Schedule
Some Travel

Job Description

Clinical Documentation Improvement Specialist
Providence, RI

Join this dynamic, growing organization

Must have a certification in Clinical Documentation Improvement
CCS; CCDS or CDIP certification

Ideal candidate is a foreign trained physician who has experience working in an acute care hospital as a Clinical Documentation Improvement Specialist, or a Registered Nurse with CDIS experience.

Under limited direction and according to clinical documentation guidelines and established policies/procedures, the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation.

Essential Functions:
•Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff to ensure the most appropriate reimbursement is achieved for the level of service rendered to all patients.
•Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes.
•Oversees clinical documentation patterns and trends to identify areas of improvement for the pay for performance measures.
•Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
•Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals.
•Compiles, analyzes and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.
•Gathers and interprets clinical documentation data, to identify discrepancies, problems or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures.
•Uses assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues.
•Articulates the program to physician and other health care professionals in order to educate and teach clinical documentation requirements for both DRG reimbursement and pay for performance quality measures.
•Facilitates the processes associated with the Documentation Improvement Initiative, encourage a spirit of cooperation among clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.

For more information please apply to this job and email your resume in a word doc to