Full Job Description
Clinical Documentation Specialist
Location: Larkin Bldg @ Exchange Street
Location of Job: US:NY:Buffalo
Work Type: Full-Time
Shift 1
Job Description
The Clinical Documentation Specialist (CDS) professionals strive to promote an accurate and meaningful database that clearly demonstrates the resources used in the patient's care. The CDS is an essential resource to the clinical team and collaborates extensively with Physicians/Providers, HIM coding team, Nursing, Patient Management, Quality Department and ancillary staff to perform concurrent analytical review of clinical documentation and coding data.The CDS facilitates obtaining appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The goal is to improve documentation of all conditions and treatments from point of entry to discharge,ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, documentation/coded quality metrics, and reimbursement. The CDS exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and/or procedures. They educate members of the patient care team regarding clinical documentation guidelines and impact, including attending Physicians, Advanced care practitioners, Residents/Medical students, Business Advisor's and other members of the health care team. The CDS is also responsible for audit review to identify potential documentation deficiencies in specific records and to identify clinical specialties that require focused interaction and physician/provider education. Clinical Documentation Specialists hired on or after January 1, 2014 must obtain a CCDS or CCS credential within three years of starting in position.
Education And Credentials
Bachelor of Science or Bachelor of Arts in Nursing or similar or Bachelors in Health care Administration required. Registered Nurse required. CDS must obtain CCDS credential within 12 months of achieving specific requirements of 2 years of experience as a Clinical Documentation Specialist.
Experience
3 years of experience in Patient Management, acute care, medical/surgical or ICU/ED as a licensed Registered Nurse required. 1 year of experience in Clinical Documentation Specialist field, coding classifications systems such as, but not limited to, ICD-CM, AP-DRG, APR -DRG, MS-DRG preferred.
Working Conditions
Essential:
* Weight Requirement - Light (up to 20 lbs)
Job Details
Department: KH Clinical Documentation
Standard Hours Bi-Weekly: 75.00
Weekend/Holiday Requirement: No
On Call Required: No
With Rotation: No
Scheduled Work Hours: 7a-3p, 7:30a-3:30p, 8a-4p
Work Arrangement: Hybrid
Union Code: N00 - Non Union KH
Requisition ID#: 9434
Grade: EX213
Pay Frequency: Bi-Weekly
Salary Range: $67,938.00 - $93,414.75
*Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.
Kaleida Health's mission is to advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission- critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community. Kaleida Health is committed to creating a culture of equity and inclusion where diversity is valued and celebrated!
