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Clinical Documentation Specialist

2 months ago

Elk Mills, Maryland, United States JobGet Full time
Job Summary

We are seeking a skilled Clinical Documentation Specialist to join our team at ChristianaCare. As a key member of our Clinical Documentation Improvement (CDI) team, you will play a critical role in ensuring the accuracy and completeness of patient documentation.

Key Responsibilities
  • Develop and implement education programs for CDI specialists and clinicians to improve documentation quality and compliance.
  • Track and trend CDI queries to identify knowledge gaps and provide clear explanations.
  • Orient new clinicians and CDI specialists to our documentation standards and best practices.
  • Create documentation education materials, including clinician-level scorecards and documentation checklists.
  • Collaborate with the coding department to provide weekly huddle education and ensure consistency in documentation practices.
Requirements
  • Bachelor's degree in nursing.
  • DE RN licensed 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 acute care, adult care setting preferred.
  • Promotes a culture of continuous improvement and learning, self-motivated learner.
  • Completes a minimum of 8 continuing education credits (CEU's) per year in Clinical Documentation Improvement.
Working Conditions

This is a hybrid position with remote and onsite requirements. Ability to ambulate within the hospital setting, occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs for long periods of time.

About ChristianaCare

Delivering health, not just healthcare, is our promise to our community. We are an organization that puts patients first, delivering care to our community through our roles. We invite you to join us in our quest for excellence.

Benefits
  • Holiday Pay
  • Guaranteed Hours
  • Continuing Education
  • 403b retirement plan
  • Pet insurance
  • Cancelation protection
  • Wellness and fitness programs
  • Mileage reimbursement
  • Employee assistance programs
  • Medical benefits
  • Dental benefits
  • Vision benefits
  • Benefits start day 1
  • License and certification reimbursement
  • Life insurance
  • Discount program