1475-011 Clinical Documentation Specialist (CDI) - Full Time Onsite
Required: Graduate of an accredited School of Professional Nursing. Minimum required: Associates Degree
• Must possess at least five (5) years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus.
• ICU/Critical Care experience strongly desired.
• Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred.
• Prior experience educating physicians/providers preferred.
• Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.
• Minimum of one (1) year auditing experience strongly encouraged.
• This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.
• Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge is necessary.
• Prioritization and organizational skills required.
• Must exhibit the ability to educate members of the healthcare team about clinical documentation. Individual must demonstrate data quality and integrity skills.
• To perform this job successfully, an individual should have strong working knowledge of word processing software, spreadsheet software and reporting software. Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred
• English is required for both verbal and written communication.
• Ability to communicate effectively at a high level is required
Required: Current professional nursing license to practice as a Registered Nurse in the State of New Mexico or compact license
Required: ACDIS (Association of Clinical Documentation Improvement Specialists) certified - within one year of employment.
Desired: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation.