The CDS is responsible for reviewing medical record documentation to facilitate the accurate representation of the severity of illness by improving the quality and specificity of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, Coders, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Management Program (CDMP®) process is a key role.
Graduate from a program of nursing, BSN preferred or graduate of Health Information Management. Certification, Registration, and/or Licensure Registered Nurse, Certified Coding Specialist, Registered Health Information Administrator or Registered Health Information Technician
RN: Strong medical/surgical or intensive care experience CCS, RHIA, RHIT: Similar experience in coding or documentation improvement program with exceptional clinical knowledge
Use of basic software applications such as Word and Outlook or any email application plus experience with an electronic medical record system
Respect for confidential information on patients, employees, physicians, and hospital. Requires organizational, analytical, writing and interpersonal skills. Must be dependable and self directed. Needs critical thinking, problem solving and deductive reasoning skills. Must be patient and resilient in helping to implement changes with physicians.
Travels to all inpatient care areas of hospital. Could stand for extended time periods while reviewing records or using computer. Pull or pushes a cart with laptop computer and other supplies. Requires some physical movement and is on feet part of the time.