Clinical Documentation Integrity Specialist

Bayhealth Dover, DE

About the Job

Bachelor of Science

The Clinical Documentation Integrity Specialist is an RN who is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians, nursing, and ancillary staff on clinical documentation best practices.

Minimum Position Qualifications

Education: BSN Degree is required.

Experience: Minimum of 5 years acute-care experience in Med-Surg and/or Critical Care.

Additional experience in Utilization Review, Case Management, and Coding is preferred.

License/Certification: Registered Nurse (RN-BSN) with current DE license.

Additional Requirements

Attention/Concentration: Strong concentration skills. Ability to sustain concentration to a task over an extended period of time. Skill and proficiency in applying Utilization, Quality case management and coding criteria.

Learning and memory: Efficiency in processing information, either written or verbal. Able to attend to and process multiple bits of information simultaneously.

Problem Solving: Autonomy of thought. Ability to collect data, establish facts and draw conclusions and take action as appropriate.

Performance under stress: Ability to perform under stress when confronted with emergency or critical situations.

Variety and Change: Ability to perform a variety of duties often changing from one task to another of varied nature, without loss of efficiency or effectiveness.

Communication: Ability to exchange information with others clearly and concisely to present ideas, facts and clinical information; Must be proficient in reading, writing, and speaking English.

Interpersonal Relations: Ability to maintain relationships that facilitate task accomplishment, to cooperate and resolve conflicts, to recognize needs and be sensitive to others.