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Form of workJob Details:
The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate Clinical Documentation through extensive interaction with physicians, nursing staff, patient care providers, and Health Information Management coding staff to ensure the Clinical Documentation reflects the level of service rendered to patients is complete and accurate.
RESPONSIBILITES:
- Educates all members of the patient care team on documentation guidelines on an ongoing basis. Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
QUALIFICATIONS/REQUIREMENTS:
Minimum of 5-10 years acute care clinical experience, preferably with management experience. Previous CDI experience, preferred. Writing skills and knowledge of correct business English essential. Strong organizational skills required. Computer literacy and critical thinking skills required. High level of communication skills required. Able to work independently. Physical Demands/Working Conditions: Ability to maneuver a COW to workstations/on and off elevators: carry/lift up to 10lbs of charts, books, other CDI tools. Subject to stressful situations.
EDUCATION:
Registered Nurse, BSN; Masters preferred.
OTHER:
If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
About Us:
Good Samaritan Hospital
Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area’s leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children’s Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.
