Position Summary

The CDS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role.

Major Roles and Objectives:

• Ability to learn/develop the skills necessary to perform CDMP®
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible queries
• Effective and appropriate communication with physicians
• Timely follow up on all cases especially those with queries
• Participate in Task Force meetings
• Manage multiple priorities
• Communicates with HIM staff and resolves discrepancies
• Accurate input of data into CDMPTrak®

Skills Required:

• Organizational, analytical, writing and interpersonal skills
• Dependable and self directed
• Critical thinking, problem solving and deductive reasoning skills
• Recent hospital experience preferably ICU, CCU, or strong Med/Surg
• Knowledge of pathophysiology and disease process
• Basic computer skills – familiarity with Windows based software programs
• Knowledge of Medicare Part A
• Familiar with Medicare Part B
• Knowledge of regulatory environment
• Understand and support CDMP® documentation strategies
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments

Education/Licensure/Certification:

• Graduation from a program of nursing, BSN, preferred or graduate of Health Information Management RHIT, RHIA preferred
• Current state Registered Nurse license or Certified Coding Specialist

Download this document as a PDF file.