Position Summary
Intermediate level position for experienced CDS. Demonstrates all skills of CDS I with less than 5% error rate.
Position Summary: Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient caregivers, and coding staff.Develops or recommends improvements/enhancements to documentation tools, provider engagement and/or processes related to documentation and related outcomes, as needed. Assists in reconciling query and non-query impact within the CDI data entry systems. Assists in the supervision of staff. Meet with decision makers, systems owners, and end users to define requirements and goals. Participates and/or leads meetings with administrators. Performs other related and incidental duties as needed or required.
Education
Required: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
Experience
Required: 5years of CDS experience and 2 years recent acute care experience in aclinical or inpatient coding setting; or, MBBS and USMLE in lieu of experience.
Certifications
Required: RN, LVN, LPN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP and CCDS or CDIP certification
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