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Form of workClinical Documentation Improvement Specialist - Case Management
Previous CDIS experience is preferred. Certification in CCDS within 2 years of hire is required.
The role and scope of practice of a Clinical Documentation Improvement Specialist RN includes specialized training and skills not emulated in patient facing RN positions
Role is 90% remote/ability to work from home with occasional travel to Biddeford campus expected, on average, one to two times per month. Must be able to work onsite until training/orientation has been fully completed.
Position Summary
This position reports to the Manager of Case Management, and is responsible for monitoring and facilitating the overall accuracy and completeness of the medical record. Works closely with the Health Information Management department, Coders, Quality Management staff, the interdisciplinary team and Medical Staff to ensure adequate processes are instituted for the support and facilitation of complete documentation. Monitor and sponsor Medical Staff with the documentation that will support the appropriate clinical picture, or level of severity of the patient while providing accurate and complete information to be utilized in the medical record abstraction and coding process. Firmly grasps the organization's process improvement approach (PDSA) and is able to effectively communicate the process and educate others regarding its purpose and use.
Required Minimum Knowledge, Skills, and Abilities (KSAs)
Additional Information
With a career at any of the MaineHealth locations across Maine and New Hampshire, you'll be working with health care professionals that truly value the people around them - both within the walls of the organization and the communities that surround it.
We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow - programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family.
MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you're looking to build a career in a place where people help one another deliver best-in-class care, apply today.
Previous CDIS experience is preferred. Certification in CCDS within 2 years of hire is required.
The role and scope of practice of a Clinical Documentation Improvement Specialist RN includes specialized training and skills not emulated in patient facing RN positions
Role is 90% remote/ability to work from home with occasional travel to Biddeford campus expected, on average, one to two times per month. Must be able to work onsite until training/orientation has been fully completed.
Position Summary
This position reports to the Manager of Case Management, and is responsible for monitoring and facilitating the overall accuracy and completeness of the medical record. Works closely with the Health Information Management department, Coders, Quality Management staff, the interdisciplinary team and Medical Staff to ensure adequate processes are instituted for the support and facilitation of complete documentation. Monitor and sponsor Medical Staff with the documentation that will support the appropriate clinical picture, or level of severity of the patient while providing accurate and complete information to be utilized in the medical record abstraction and coding process. Firmly grasps the organization's process improvement approach (PDSA) and is able to effectively communicate the process and educate others regarding its purpose and use.
Required Minimum Knowledge, Skills, and Abilities (KSAs)
- Education: Bachelor Degree or matriculation in a Bachelor's Degree program preferred.
- License/Certifications: Current Registered Nurse Licensure from the Maine State Board of Nursing.
- Experience: Five years of acute care clinical setting nursing experience. Interest and experience in project management, process improvement, and research through the review and use of evidence-based practice is preferred. Knowledge and experience in Clinical Documentation improvement, utilization management, discharge planning and Case Management preferred.
- Is responsible for maintaining a current knowledge of the nursing practices contemporary to the legal framework of the Nurses Practice Act, and in accordance with regulatory requirements and ethical guidelines.
Additional Information
With a career at any of the MaineHealth locations across Maine and New Hampshire, you'll be working with health care professionals that truly value the people around them - both within the walls of the organization and the communities that surround it.
We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow - programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family.
MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you're looking to build a career in a place where people help one another deliver best-in-class care, apply today.
