Job Information
Rochester Regional Health Clinical Documentation Specialist in Potsdam, New York
Description SUMMARYThe CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.STATUS: Full TimeLOCATION: St. Lawrence HealthDEPARTMENT: Clinical Documentation Improvement SCHEDULE: Monday - Friday DaysATTRIBUTES3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU. Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD. RESPONSIBILITIESReviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality Accurate and timely record review Recognize opportunities for documentation improvement Formulate clinically credible documentation clarifications Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety Effective and appropriate communication with physicians Provides education to members of the patient care team regarding the CDS process. Timely follow up on all cases and resolution of those with clinical documentation clarifications PHYSICAL REQUIREMENTS: S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.PAY RANGE: $78,000.00 - $95,000.00 The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts. Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/VeteranApply here: https://www.aplitrak.com/?adid=YmJnZW5lcmljLjkyOTUyLjEwNDE3QHJvY2hlc3RlcnJlZ2lvbmFsY29tcC5hcGxpdHJhay5jb20
Minimum Salary: 78000.00 Maximum Salary: 95000.00 Salary Unit: Yearly