Boulder Community Hospital RN Clinical Documentation Specialist in Boulder, Colorado
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.
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
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