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Clinical Documentation Specialist

2 months ago

Newark, Delaware, United States ChristianaCare Full time
Job Title: Clinical Documentation Specialist

ChristianaCare is seeking a skilled Clinical Documentation Specialist to support documenting clinicians and CDI staff to improve the quality, accuracy, and overall completeness of inpatient clinical documentation.

Job Summary:

The Clinical Documentation Specialist will provide leadership and support for systemwide best practice documentation and coding that are consistent with the organizational mission, priority, and goals. The ideal candidate will work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and clinicians.

Key Responsibilities:
  • Work with program leadership to plan, develop, and implement clinical documentation education programs for CDI specialists and clinicians.
  • Tracks, trends, and audits CDI queries to ensure quality and compliance while using an auditing tool. Identifies knowledge gaps, provides clear explanations.
  • Orient new clinicians and Clinical Documentation Specialists.
  • Creates documentation education/references: Clinician level score cards, documentation checklist/tool per specialty and create documentation material (Tip Cards, flyers, etc.).
  • Collaborates with the coding department for weekly huddle education.
Requirements:
  • Bachelor's degree in nursing.
  • DE RN licensed or Compact Nursing License.
  • Strong medical terminology & clinical awareness.
  • Effective communication and clinical skills.
  • Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
  • Minimum of 3 years CDI experience. 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:

Limited patient contact. Normal office environment. Possible remote work opportunities.