You’ll need
Certifications
✓Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification is required.
Education
✓Must have a degree in nursing from an accredited college or university.
✓Master’s Degree in a Healthcare/Medical related field from an U.S. accredited college or university
✓Graduated from an accredited Health Information Management coding program
✓Equivalent Education and/or Experience
✓May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.
Qualifications
✓For RNs: Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)
✓For HIM Professionals: Must have two plus (2+) years of inpatient coding experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes.
✓RN/HIM Professionals must have Two plus (2+) years of experience working in clinical documentation integrity
✓Organizational, analytical, writing and interpersonal skills.
✓Must be able to be comfortable speaking and teaching in group settings
✓Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.
✓Must be able to communicate effectively with physicians, nursing and ancillary staff.
✓Must be able to demonstrate patient centered/patient valued behaviors.
✓Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures.
✓Must have knowledge of ICD-10-CM and ICD-10-CM/PCS coding conventions and/or clinical auditing processes.
✓Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint.
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About the role
The Clinical Documentation Integrity Specialist (CDIS) applies clinical knowledge to analyze and to interpret health records. Proficiently applies ICD-10, CPT, SOI/ROM coding to in-house patients. Analyzes records for optimization of physician documentation and query potential, if required.