Cape Cod Healthcare

RN, Clinical Documentation Specialist

Cape Cod Healthcare • $80K — $95K *
Hyannis, MA 02601Hybrid
Healthcare
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Graduate of a School of Nursing
  • Currently licensed as a Registered Nurse in Massachusetts
  • Bachelor of Science in Nursing (BSN) for external applicants only
  • Minimum of 3 years of current RN, CDI practice experience
  • Certified Clinical Documentation Specialist (CDI) or CCHC Clinical Documentation Specialist Exam certification or equivalent
  • Strong analytical, organizational, writing, and interpersonal skills
  • Knowledge of Medicare guidelines and regulatory environment

Responsibilities

  • Review and analyze medical records for accurate clinical documentation
  • Engage directly with physicians and clinical staff during documentation improvement
  • Participate actively in team meetings and educate staff on CDI processes
  • Formulate clinically relevant queries to support documentation accuracy
  • Ensure timely follow-up on all cases, especially those needing clarification
  • Resolve discrepancies by communicating with Health Information Management (HIM) team
  • Input data accurately into the electronic medical record

Benefits

  • Participation in collaborative Task Force meetings
  • Opportunities for professional growth in clinical documentation
  • Access to continuous education and training in the CDI process
  • Supportive teamwork environment prioritizing service excellence
  • Engagement with a multidisciplinary healthcare team
  • Flexible management of priorities within a dynamic work setting
Full Job Description
Purpose of Position
The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians' clinical documentation.

Description
  1. Extensive record review, interaction with physicians, HIM professionals, and nursing staff.
  2. Active participation in team meetings and education of staff in the CDI process is a key role.
  3. Ability to learn/develop the skills necessary to perform CDI duties.
  4. Accurate and timely record review.
  5. Recognize opportunities for documentation improvement.
  6. Formulate clinically credible queries.
  7. Effective and appropriate communication with physicians.
  8. Timely follow up on all cases especially those with queries.
  9. Participate in Task Force meetings.
  10. Manage multiple priorities.
  11. Communicates with HIM staff and resolves discrepancies.
  12. Accurate input of data into the electronic medical record.
  13. Understand and support clinical documentation strategies.
  14. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
  15. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.


Qualifications
RN, Clinical Documentation Specialist - Grade: NSI4, Job Code: 3057
  • Graduate of a School of Nursing
  • ( RN ) - Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
  • (BSN) - A Bachelor of Science in Nursing (external applicants only)
  • Minimum of 3 years of current RN, CDI Practice experience
  • Must meet at least one of the following qualifications:
    1. Certified Clinical Documentation Specialist (CDI)
    2. CCHC Clinical Documentation Specialist Exam
  • Knowledge of Medicare Part A and Part B
  • Knowledge of regulatory environment
  • Organizational, analytical, writing and interpersonal skills
  • Dependable and self-directed
  • Critical thinking, problem solving and deductive reasoning skills
  • Knowledge of pathophysiology and disease process
  • Basic computer skills - familiarity with Windows based software programs
  • Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers

About Cape Cod Healthcare

Cape Cod Healthcare is a healthcare system that provides medical services to residents of Cape Cod, Massachusetts. The system includes two hospitals, several outpatient facilities, and a physician network. Cape Cod Healthcare was founded in 1996 and is headquartered in Hyannis, Massachusetts.
Learn more about Cape Cod Healthcare
Size
5,000 employees
Industry
Healthcare
Founded
1984
* Ladders Estimates

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