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5 Full-time 13 hours ago Full Job Description Job
Summary:
The Clinical Documentation Specialist 1 (CDS) is responsible for improving the overall quality and completeness of clinicaldocumentation in the medical record to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients.
.
This position involves concurrent medical record review, DRG validation, querying providers, capture of clinical and quality indicators to ensure the thoroughness of documentation prior to coding and billing.
Education – Required:
Bachelor’s Degree Nursing or Master’s Degree Experience – Required:
5 years Advanced clinical experience in an acute care hospital setting.
.
or 2 years 1-2 years of CDI or Coding experience Knowledge, Skills, and Abilities – Required:
Experience with medical record reviews and/or DRG validation.
Proficient in MS Outlook, Word, Excel and PowerPoint.
.
Will acquire working knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements Will demonstrate adaptability and self-motivation to stay abreast of CMS rules and regulations; incorporate those changes into daily practice; maintain knowledge of federal, state and private payor regulations and demonstrate knowledge and understanding of ICD-10 Coding Guidelines.
Will demonstrate accountability, professional development, and adhere to departmental policies and guidelines.
.
Licensure – Required:
Registered Nurse Upon Hire or Physician Assistant Upon Hire Certifications – Required:
ACDIS – Certified Clinical Documentation Specialist Within 2 Years of Hire within 2 Years Certified Professional Coder Upon Hire or Certified Coding Specialist Upon Hire or Registered Health Information Administrator Upon Hire or Registered Health Information Technician Upon Hire Location:
Lehigh Valley Health Network Physician Documentation Schedule:
Full Time 40 hours, Day Shift, 8:
00a-4:
30p.
5 Full-time 13 hours ago Full Job Description Job
Summary:
The Clinical Documentation Specialist 1 (CDS) is responsible for improving the overall quality and completeness of clinicaldocumentation in the medical record to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients.
.
This position involves concurrent medical record review, DRG validation, querying providers, capture of clinical and quality indicators to ensure the thoroughness of documentation prior to coding and billing.
Education – Required:
Bachelor’s Degree Nursing or Master’s Degree Experience – Required:
5 years Advanced clinical experience in an acute care hospital setting.
.
or 2 years 1-2 years of CDI or Coding experience Knowledge, Skills, and Abilities – Required:
Experience with medical record reviews and/or DRG validation.
Proficient in MS Outlook, Word, Excel and PowerPoint.
.
Will acquire working knowledge of DRG assignment and methodology, coding practices and clinical documentation requirements Will demonstrate adaptability and self-motivation to stay abreast of CMS rules and regulations; incorporate those changes into daily practice; maintain knowledge of federal, state and private payor regulations and demonstrate knowledge and understanding of ICD-10 Coding Guidelines.
Will demonstrate accountability, professional development, and adhere to departmental policies and guidelines.
.
Licensure – Required:
Registered Nurse Upon Hire or Physician Assistant Upon Hire Certifications – Required:
ACDIS – Certified Clinical Documentation Specialist Within 2 Years of Hire within 2 Years Certified Professional Coder Upon Hire or Certified Coding Specialist Upon Hire or Registered Health Information Administrator Upon Hire or Registered Health Information Technician Upon Hire Location:
Lehigh Valley Health Network Physician Documentation Schedule:
Full Time 40 hours, Day Shift, 8:
00a-4:
30p.
