MCMC

Outpatient Clinical Documentation Information Specialist

US-OR-The Dalles
ID
2017-3207
# of Openings
1
Category
Supporting Staff
Type
Regular Full-Time
Shift
Days
Department : Name
ADMINISTRATION
Min
USD $35.35/Hr.
Max
USD $44.19/Hr.
Salary Grade
36

Overview

Mid-Columbia Medical Center is seeking a qualified Outpatient Clinical Documentation Information Specialist. 

 

This position is Full-Time and is eligible for a comprehensive benefits package.

Responsibilities

The Clinical Documentation Improvement Specialist (CDIS) facilitates accurate, complete, consistent and timely documentation for severity of illness, expected risk of mortality, and complexity of care of the patient, improving the quality of the clinicians’ clinical documentation completed in the outpatient clinic setting. This involves extensive record review, interaction with physician/non-physician providers, health information management professionals, nursing staff, financial staff and other clinic office staff.  Active participation in team meetings and education of providers and staff is required.

 

Qualifications

Minimum Education, Training & Experience (includes licenses or certifications):

Education:

  • Graduation from a program of nursing, (BSN, preferred).
  • Current state Registered Nurse License.
  • Certification as an RHIT or CCDS preferred

Experience:

  • Required: 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU
  • Required: at least 2 years of adult ambulatory/ outpatient care
  • Preferred: 1 year of Clinical Documentation Improvement (CDI) experience in the inpatient/outpatient setting 
  • Preferred: Experience in utilization review, coding and billing- ICD-10

 

Skills/Knowledge/Abilities:

  • Ability to learn and develop the skills necessary to perform CDIS in the ambulatory setting
  • Organizational, analytical, writing and interpersonal skills
  • Dependable, self-directed and pleasant
  • Critical thinking, problem solving and deductive reasoning skills
  • Knowledge of pathophysiology and disease process
  • Basic computer skills – familiarity with Windows and Microsoft based software programs
  • Knowledge of regulatory environment
  • Understand and support CDI documentation strategies (upon completion of training)
  • Understand and communicate differences between Medicare Part A and B payment methodologies [i.e., CMS Hierarchical Condition Categories (HCCs), RX HCCs, HHS HCCs, etc.] and how documentation impacts HCC capture and assignment (upon completion of training)

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