The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.
Extensive knowledge of ICD-10-CM/PCS classifications and coding of diagnoses and procedures is required. In depth knowledge of medical terminology, human anatomy/physiology, pharmacology, and pathology is required. RN license + 3 years clinical and CDI experience required AND CCDS or CDIP certification OR Coder with 5 years Inpatient coding experience, 3 years CDI experience with CCS, CIC, RHIA, RHIT AND CCDS or CDIP (2 certifications required - Coding and CDI) The ability to problem solve and to communicate in a professional manner with staff and other health care professionals is essential. Prior CDI work experience preferred. Knowledge of computer technology, quality assurance activities, DRG, Utilization review highly preferred Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required. Detail oriented individual with excellent organizational skills. High degree of oral and written communication skills. Traveling may be required as necessary. Graduate of an approved Health Record Administration or Accredited Medical Record Technician program (RHIA/RHIT or eligible) or a certified coding program or 3 years clinical acute care nursing experience medical/surgical to include critical care in conjunction with expanding knowledge of DRGs. 3 years relevant experience - preferably 3 years of auditing experience or clinical acute care nursing experience with expanded knowledge of DRGs.
Licensure, Certifications, and Clearances:
RN or CRNP AND CCDS or CDIP OR CCS or CIC or RHIA or RHIT AND CCDS or CDIP
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities