Clinical Documentation Improvement Specialist RN

Overview

Central Maine Healthcare is an integrated healthcare delivery system serving 400,000 people living in central, western and Midcoastal Maine. CMH's hospital facilities include Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital. CMH also supports Central Maine Medical Group, a primary and specialty care practice organization. Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services.

 

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.  He/She will perform other duties as assigned or required.

Qualifications

 

Required Qualifications:

Medical Graduate, PA or Nursing Graduate

Minimum of one (1+) year’s clinical experience in an acute care setting

Knowledge of care delivery documentation systems and related medical record documents

Knowledge of age-specific needs and the elements of disease processes and related procedures

Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

Excellent written, and verbal communication skills and critical thinking skills.

Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.

Working knowledge of inpatient admission criteria.

Ability to work independently in a time-oriented environment.

Computer literacy and familiarity with the operation of basic office equipment.

Assertive personality traits to facilitate ongoing physician communication.

 

Preferred Qualifications:

ECFMG Certificate or RN license

Prior Case Management Experience

Working knowledge of the Medicare reimbursement system and coding structures   

Current BCLS (AHA) certificate upon hire and maintain current.

ACLS Certificate

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf