CDI Specialist, RN (2018)
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Job Location:
Monthly Salary:
Posted on:
3 days ago
Vacancies:
1 Vacancy
Job Summary
This position is responsible for improving the overall quality and completeness of clinical documentation for inpatient admissions Same Day Surgery Observation and Emergency Trauma Center encounters. This position facilitates concurrent modifications to clinical documentation through extensive interaction with physicians and other providers Clinical Excellence and Patient Safety (CEPS) nursing staff other patient care givers and HIM coding staff to ensure clinical severity and services rendered to patients are accurately reflected in the documentation. This requires review of appropriate diagnosis procedures and working DRGs/APCs based on clinical indicators to assure appropriate clinical severity is captured. This position also ensures the accuracy and completeness of clinical information used for measuring and reporting physician data and Trinity Health outcomes. Educates members of the patient care team on documentation related issues on an ongoing basis. The Clinical Documentation Specialist reports to the Enterprise Director of HIM/CDI.
Licenses and Certifications Required Current or temporary RN license in ND or compact RN licensure or Licensed Practical Nurse or LPN designation required; OR Certified Clinical Documentation Specialist (CCDS) from ACDIS or Clinical Documentation Improvement Professional (CDIP) from AHIMA required. Educational Requirements Associate or Bachelors Degree in Nursing required; OR Associate or Bachelors Degree in Health Information Management (RHIT or RHIA) or other Clinical Healthcare field required. Experience Requirements A minimum of 3 years clinical experience in an acute care or outpatient (Same Day Surgery Emergency Room or Observation) setting is required; OR a minimum of 5 years acute care same day surgery ER or observation) coding experience required. Special Skills or Training Requirements Dependable self-directed. Critical thinking problem solving organizational and deductive reasoning skill. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge an understanding of pathology/physiology of disease processes. Knowledge of medical record documentation requirements and computer literacy is required. Excellent written and verbal communication skills. Excellent interpersonal skills to build effective partnering relationships with physicians nurse staff and hospital management staff. Willingness to learn and incorporate knowledge into day-to-day working environment: Knowledge of inpatient admission criteria; Understanding of complications comorbidities severity
Licenses and Certifications Required Current or temporary RN license in ND or compact RN licensure or Licensed Practical Nurse or LPN designation required; OR Certified Clinical Documentation Specialist (CCDS) from ACDIS or Clinical Documentation Improvement Professional (CDIP) from AHIMA required. Educational Requirements Associate or Bachelors Degree in Nursing required; OR Associate or Bachelors Degree in Health Information Management (RHIT or RHIA) or other Clinical Healthcare field required. Experience Requirements A minimum of 3 years clinical experience in an acute care or outpatient (Same Day Surgery Emergency Room or Observation) setting is required; OR a minimum of 5 years acute care same day surgery ER or observation) coding experience required. Special Skills or Training Requirements Dependable self-directed. Critical thinking problem solving organizational and deductive reasoning skill. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge an understanding of pathology/physiology of disease processes. Knowledge of medical record documentation requirements and computer literacy is required. Excellent written and verbal communication skills. Excellent interpersonal skills to build effective partnering relationships with physicians nurse staff and hospital management staff. Willingness to learn and incorporate knowledge into day-to-day working environment: Knowledge of inpatient admission criteria; Understanding of complications comorbidities severity
Required Experience:
IC
Key Skills
- Sales Experience
- Crane
- Customer Service
- Communication skills
- Heavy Equipment Operation
- Microsoft Word
- Case Management
- OSHA
- Team Management
- Catheterization
- Microsoft Outlook Calendar
- EHS
About Company
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians caring for diverse communities across 25 states. Nationally recognized for care and experience, the Trinity ... View more
