Clinical Documentation Specialist (RN) Details

Clinical Documentation Specialist (RN)

Medstar Georgetown University Hospital - Washington, DC

Employment Type : Full-Time

MedStar Georgetown University Hospital is a not-for-profit, acute-care teaching and research hospital with 609 beds located in Northwest Washington, D.C. Founded in the Jesuit principle of cura personalis—caring for the whole person—MedStar Georgetown is committed to offering a variety of innovative diagnostic and treatment options within a trusting and compassionate environment.

MedStar Georgetown’s centers of excellence include neurosciences, transplant, cancer and gastroenterology. Along with Magnet® nurses, internationally recognized physicians, advanced research and cutting-edge technologies, MedStar Georgetown’s healthcare professionals have a reputation for medical excellence and leadership.

General Summary of Position:

The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The CDS performs concurrent clinical documentation chart reviews to ensure the medical record appropriately describes the patient’s severity of illness and risk of mortality. The CDS develops compliant physician queries guided by the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Improvement Professionals”. In addition, the CDS may review medical records retrospectively, in accordance to the Hospital’s CDI Policies and Procedures, to identify whether or not the physician responded to a query placed concurrently. These functions are performed in accordance with all applicable laws and regulations and MedStar Georgetown University Hospital's philosophy, policies, procedures and standards.

Qualifications:

Education, Certifications and or Training Required

• Bachelor of Science Degree in a related field; RN, BSN preferred.
• Clinical Documentation Specialist credential (CDIP or CCDS), preferred; Upon hire must become AHIMA or ACDIS certified in CDI within 12 months of becoming eligible for the exam.
• Consideration will be provided for clinicians (i.e. graduates of medical schools outside the U.S. but not yet licensed to practice in the U.S.).
• If a registered nurse, must be a graduate of an accredited school of nursing, and hold a current D.C. license as a Registered Nurse.

Experience

• Three years clinical experience in a tertiary hospital.
• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems, preferred
• Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff.
• Demonstrates effective written and verbal communication skills.
• Demonstrates critical-thinking skills and strong clinical knowledge.
• Is proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool.
• Ability to collect and analyze data related to the CDI program.