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Clinical Documentation Specialist

2 months ago

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

Shaker for ChristianaCare Direct is seeking a highly skilled Registered Nurse (RN) to join our team as a Clinical Documentation Integrity Quality & Safety Specialist. This role is responsible for 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 develop targeted physician education to achieve department goals.
  • Manage, coach, and mentor less experienced healthcare personnel in best practice documentation, focusing on quality and safety.
  • Ensure all concurrent and retrospective queries are clinically relevant and escalate to Physician Champions as necessary.
  • Facilitate DRG Reconciliation and provide feedback to CDS/Coding and Leadership.
  • Actively participate in systemwide management activities, attending meetings and in-service/educational programs as requested.
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:

Limited patient contact, normal office environment, and possible remote work opportunities.