Cape Cod Healthcare

RN, Clinical Documentation Specialist (CDI)

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

Qualifications

  • Graduate of a School of Nursing
  • RN - Currently licensed in Massachusetts
  • BSN required for external applicants
  • Minimum 3 years of current RN, CDI Practice experience
  • Certification as Clinical Documentation Specialist (CDI) or CCHC Clinical Documentation Specialist Exam completion required
  • Strong understanding of Medicare Part A and Part B guidelines
  • Proficient in organizational, analytical, writing, and interpersonal skills

Responsibilities

  • Conduct extensive review of medical records
  • Interact collaboratively with physicians and healthcare professionals
  • Participate actively in team meetings and staff education
  • Identify opportunities for improving clinical documentation
  • Formulate queries that are clinically credible
  • Ensure timely follow-ups on documentation cases
  • Communicate effectively with HIM staff and resolve discrepancies

Benefits

  • Service excellence culture towards patients and colleagues
  • Collaborative team environment
  • Opportunities for professional development and skill enhancement
  • Engagement in Task Force meetings
  • Supportive leadership in clinical documentation strategies
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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