Clinical Documentation Improvement Specialist (CDS) - Milford Regional Medical Center

16 hours , Monday - Friday, 8:00 AM to 4:30 PM, no weekends and Holidays

Milford Regional Medical Center is a full-service, community and regional teaching hospital located in Milford, Mass. and serves patients from more than 20 towns in Central Massachusetts. The 149-bed medical center is a nonprofit, acute-care facility, where more than 300 primary care and specialty physicians are committed to providing exceptional healthcare services to our community with dignity, compassion and respect.

Statement of Purpose:
The Clinical Documentation Improvement Specialist (CDS) is responsible for reviewing the medical record for technical accuracy, specificity, and completeness of provider clinical documentation. The CDS is responsible for initiating and completing the query process to ensure complete documentation. CDSs are expected to collaborate with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient.

Qualifications:

Education: Bachelor of Science in Nursing preferred, or equivalent combination of relevant education/experience.

Certification/License:
CCDS or CDIP is required; if not certified must be able to obtain within 2 years
Registered Health Information Administrator/Registered Health Information Technologist (RHIA/RHIT) or Certified Coding Specialist
If a Nurse: Licensed Registered Nurse in MA

Experience:
Nurses: Minimum of 5 years clinical expertise and extensive knowledge of complex disease processes with broad experience in an inpatient setting.
RHIA/RHIT/CCS: Documented education in anatomy/physiology & pharmacology
Proficient with 3M 360, or other CDI and coding software products
Working knowledge of quality improvement theory and practice
Ability and willingness to seek out and accept change
Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice
Proficient in federal, state, and private payer regulations
Understanding of Microsoft Office products: Outlook, Word, Excel, PowerPoint,
Excellent oral and written communication skills with providers and other healthcare professionals
Excellent critical thinking skills, able to assess, evaluate and ability to educate providers about documentation improvement.