Clinical Document Improvement Specialist - Case Management
Southern Maine Health Care | Biddeford, ME
- Position Summary
- This position reports to the Manager of Case Management, and is responsible for monitoring and facilitating the overall accuracy and completeness of the medical record. Works closely with the Health Information Management department, Coders, Quality Management staff, the interdisciplinary team and Medical Staff to ensure adequate processes are instituted for the support and facilitation of complete documentation. Monitor and sponsor Medical Staff with the documentation that will support the appropriate clinical picture, or level of severity of the patient while providing accurate and complete information to be utilized in the medical record abstraction and coding process. Firmly grasps the organizations process improvement approach (PDSA) and is able to effectively communicate the process and educate others regarding its purpose and use.
- Required Minimum Knowledge, Skills, and Abilities (KSAs)
- Current Registered Nurse Licensure from the Maine State Board of Nursing.
- Bachelor Degree or matriculation in a Bachelor's Degree program preferred.
- Five years of acute care clinical setting nursing experience.
- Is responsible for maintaining a current knowledge of the nursing practices contemporary to the legal framework of the Nurses Practice Act, and in accordance with regulatory requirements and ethical guidelines.
- Interest and experience in project management, process improvement, and research through the review and use of evidence-based practice is preferred.
- Knowledge and experience in clinical documentation improvement, utilization management, discharge planning and case management preferred.