Boulder Community Hospital RN Clinical Documentation Specialist in Boulder, Colorado

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POSITION SUMMARY

The CDS is responsible for reviewing medical records to evaluate overall completeness and quality of clinical documentation and to facilitate the accurate representation of the severity of illness primarily for quality reporting and DRG assignment. This involves extensive record review, interaction with physicians, HIM professionals, nursing staff, case managers and coding staff. Active participation in team meetings and education of staff in the CDMP process is a key role.

JOB QUALIFICATIONS

EDUCATION OR FORMAL TRAINING

Graduate from a program of nursing, BSN preferred

SPECIAL QUALIFICATIONS (licensure, registration, etc.)

Current state Registered Nurse license

Coding certification preferred

KNOWLEDGE, SKILL AND ABILITY

Recent hospital experience preferably ICU, CCU or strong Med/Surg.

Knowledge of Pathophysiology and Disease Process

EXPERIENCE

Five years recent clinical experience in a hospital setting and working knowledge of ICD-9 coding/DRG assignment

MATERIALS AND EQUIPMENT DIRECTLY USED

Laptop, Computer, Phone

WORKING ENVIRONMENT/PHYSICAL ACTIVITIES

Sitting at a desk, walking to floors

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