Clinical Documentation Specialist II - 8 Hour Days
Summary
Reviews and improves clinical documentation in a hospital, creating queries for physicians and mentoring junior staff to ensure accurate patient records.
Job Description
The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.Qualifications
Education
- High School Diploma/GED - minimum
- Assoc. Degree/College Diploma Clinical Degree – Nursing, Health Information or Foreign Trained Medical graduate. - preferred
Experience
- 2 years Performing CDI reviews within an acute care facility or bedside experience - minimum
- 3 years Utilization review, coding or case management experience - preferred
Licenses and Certifications
- Certified Clinical Documentation Specialist (CCDS)
- Registered Health Info Admin - (RHIA)
- Clinical Documentation Integrity Practitioner (CDIP)