Clinical Documentation Specialist

2 months ago


Columbus, Ohio, United States Shaker for ChristianaCare Direct Full time
Job Title: Clinical Documentation Integrity Quality & Safety Specialist

We are seeking a highly skilled Registered Nurse to join our team as a Clinical Documentation Integrity Quality & Safety Specialist. This role will focus on ensuring the accuracy and completeness of clinical documentation, while also promoting quality and safety initiatives within our organization.

Key Responsibilities:
  • Participate in performance improvement activities to enhance documentation and coding practices.
  • Review targeted encounters for completeness and accuracy, collaborating with Physician Advisors as needed.
  • Utilize Vizient tools and data to identify documentation opportunities and provide targeted physician education to achieve department goals.
  • Manage, coach, and mentor less experienced healthcare personnel in best practice documentation, specifically those associated with quality and safety.
  • Ensure all concurrent and retrospective queries are clinically relevant and escalate to Physician Champions as appropriate.
  • Facilitate DRG Reconciliation and provide feedback to CDS/Coding and Leadership.
Requirements:
  • Bachelor's degree in nursing.
  • Delaware RN License or compact nursing license.
  • Strong medical terminology and clinical awareness.
  • Effective communication and clinical skills.
  • Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
  • Minimum of 3 years CDI experience, with a focus on PSIs preferred.
  • Minimum of 3 years recent experience as a Registered Nurse in an inpatient acute care hospital setting, preferred.
Working Conditions:

This role will be based in Newark, DE, and will involve occasional sitting, standing, and lifting loads of 5-10 pounds. The ability to utilize computer equipment and programs is essential. Prolonged daily review of charts on a computer screen and sitting for extended periods are also required.



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