Position Summary:
In this role, the Clinical Documentation Specialist (OUTPATIENT) (CDS) is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a pre-visit basis. The CDS promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients' severity of illness. The CDS obtains appropriate Clinical Documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding Clinical Documentation.
Clinical Documentation Specialist Education and Experience Requirements:
• Must have a Bachelor's degree in Nursing from an accredited academic body.
• Must be actively licensed as a Registered Nurse within the state of Illinois.
• Must have a minimum of two years' experience working as a Clinical Documentation Specialist
• Must have basic computer skills in word processing and spreadsheet utilization.
• Must have excellent interpersonal skills necessary to develop and foster effective physician communication.
• Must have the analytic skills necessary to clinically assess medical records.
• Must have excellent prioritization and organizational skills.
• Holding the CCS coding credential is preferred.
• Holding a Master's degree in a healthcare-related field is preferred.
• Experience working in Case Management, Med/Surg, or Critical Care Nursing preferred
Work Shift Details:
Days, Outpatient CDI
Department:
CLINICAL DOCUMENTATION