Clinical Documentation Specialist, CDS, CCDS, CDIP

at  Ascension

DETAILS

• Department: Clinical Documentation Integrity, Must have previous or current inpatient CDI experience
• Schedule: Full Time Days, Monday - Friday, with flexibility and paid holidays
• Hospital: Remote
• Location: Indiana
  This position is a great fit for RN’s with current or previous inpatient Clinical Documentation Integrity or Clinical Documentation Specialist experience. Candidates without previous CDI experience will not be considered at this time for this role, but are encouraged to apply to other roles within Ascension!

REQUIREMENTS

Licensure / Certification / Registration:

• One or more of the following required:
• Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation ImprovementSpecialists obtained prior to hire date or job transfer date.
• Registered Nurse credentialed from the Indiana Board of Nursing obtained prior to hire date or job transfer date.
• Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

Education:

• High School diploma equivalency with 2 years of cumulative experience OR Associate’s degree/Bachelor’s degree OR 4 years of applicable cumulative job specific experience required.

Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.

• Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
• Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
• Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient’s discharge.
• Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.