Clinical Documentation Spec

71221BR

Auto req ID:

71221BR

Department:

24421 - KH Clinical Documentation

Job Description:

The Clinical Documentation Specialiist (CDS) professionals strive to promote an accurate and meaningful database that clearly demonstrates the resources used in the patient's care. The CDS is an essential resource to the clinical team and collaborates extensively with Physicians/Providers, HIM coding team, Nursing, Patient Management, Quality Department and ancillary staff to perform concurrent analytical review of clinical documentation and coding data.The CDS facilitates obtaining appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The goal is to improve documentation of all conditions and treatments from point of entry to discharge,ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, documentation/coded quality metrics, and reimbursement. The CDS exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and/or procedures. They educate members of the patient care team regarding clinical documentation guidelines and impact, including attending Physicians, Advanced care practitioners, Residents/Medical students, Business Advisor's and other members of the health care team. The CDS is also responsible for audit review to identify potential documentation deficiencies in specific records and to identify clinical specialties that require focused interaction and physician/provider education.

Buffalo, NY

Location:

Larkin Bldg @ Exchange Street

Recruiter:

Alex Yebernetsky

Minimum or Preferred Qualifications:

Bachelor of Science or Bachelor of Arts in Nursing or similar or Bachelors in Health care Administration required. 3 years of experience in Patient Management, acute care, medical/surgical or ICU/ED as a licensed Registered Nurse required. 1 year of experience in Clinical Documentation Specialist field, coding classifications systems such as, but not limited to, ICD-CM, AP-DRG, APR -DRG, MS-DRG preferred. Registered Nurse required. CDS must obtain CCDS credential within 12 months of achieving specific requirements of 2 years of experience as a Clinical Documentation Specialist.

Status:

Full Time

Shift:

Days

Scheduled Work Hours:

8a-4p

Salary Range:

$64,786-$99,938 annually Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.

Grade:

12

Position:

Clinical Documentation Spec

Union Code:

00 - Non Union

Bi-Weekly Hours:

75

Weekend/ Holiday Requirement:

No Weekends or Holidays Required

Equal Opportunity Employer

Kaleida Health is committed to diversity and believes our workforce is strengthened by the inclusion of and respect for our differences.

Kaleida Health is an equal opportunity and affirmative action employer. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, religion, sex, national origin, citizenship status, creed, gender, gender identity or expression, sexual orientation, disability, veteran status or any other factor which cannot lawfully be used as a basis for an employment decision.

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