Clinical Documentation Specialist

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POST DATE 9/13/2016
END DATE 10/8/2016

Cape Cod Healthcare Hyannis, MA

Hyannis, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Job Description:

Cape Cod Healthcare


Clinical Documentation Specialist
Case Management
Day Shift
8a-4:30p, Rot Days, Rot W/E, Rot Hol.
Job Details:

RN for Case Management Department
Cape Cod Healthcare is the leading provider of healthcare services for residents and visitors of Cape Cod. With more than 450 physicians, 4,700 employees, and 1,100 volunteers, Cape Cod Healthcare operates two-acute care hospitals, the Cape's leading provider of homecare and hospice services (VNA), a skilled nursing and rehabilitation facility (JML Care Center), an assisted living facility (Heritage at Falmouth), the Cape's only local laboratory service (CCHC Laboratory Services) and numerous health programs. We are currently seeking a dedicated Clinical Documentation Specialist to join our team at Cape Cod Hospital.

SUMMARY: The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians' clinical documentation.


1. Extensive record review, interaction with physicians, HIM professionals, and nursing staff.

2. Active participation in team meetings and education of staff in the CDMP process is a key role.

3. Ability to learn/develop the skills necessary to perform CDMP

4. Accurate and timely record review

5. Recognize opportunities for documentation improvement

6. Formulate clinically credible queries

7. Effective and appropriate communication with physicians

8. Timely follow up on all cases especially those with queries

9. Participate in Task Force meetings

10. Manage multiple priorities

11. Communicates with HIM staff and resolves discrepancies

12. Accurate input of data into CDMPTrak

13. Understand and support CDMP documentation strategies

14. Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare's commitment to CARES: compassion, accountability, respect, excellence and service.

* Organizational, analytical, writing and interpersonal skills
* Dependable and self directed.
* Critical thinking, problem solving and deductive reasoning skills
* Recent acute care experience required, preferably ICU, CCU, or strong Medical/Surgical
* Knowledge of pathophysiology and disease process
* Basic computer skills familiarity with Windows based software programs
* Knowledge of Medicare Part A and Part B.
* Knowledge of regulatory environment
* Graduation from a program of nursing
* Bachelor of Science in Nursing required
* Current Massachusetts Registered Nurse license
* Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
* Management/supervisory experience preferred

* ***Must take JATA Clinical Competency Exam***

2 years of relevant RN experience required for per diem positions.

HR Use Only:

Zip Code: 02601