Clinical Documentation Improvement Specialist
5 days ago
Job Summary:
Milford Regional Medical Center seeks a dedicated Clinical Documentation Improvement Specialist to join our team. As a member of our healthcare community, you will play a vital role in ensuring the accuracy and completeness of medical records.
Key Responsibilities:
- Review medical records for technical accuracy, specificity, and completeness of provider clinical documentation.
- Initiate and complete the query process to ensure complete documentation.
- Collaborate with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation.
Qualifications:
Bachelor of Science in Nursing preferred, or equivalent combination of relevant education/experience.
CCDS or CDIP certification required; if not certified, must be able to obtain within 2 years.
Registered Health Information Administrator/Registered Health Information Technologist (RHIA/RHIT) or Certified Coding Specialist.
Minimum 5 years clinical expertise and extensive knowledge of complex disease processes with broad experience in an inpatient setting.
Proficient with 3M 360, or other CDI and coding software products.
Working knowledge of quality improvement theory and practice.
Excellent oral and written communication skills with providers and other healthcare professionals.
Ability and willingness to seek out and accept change.
Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
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