Clinical Documentation Specialist – Health Information Management 


Frisbie Memorial Hospital

Job Description:

Clinical Documentation Specialist – Health Information Management 
Frisbie Memorial Hospital, Rochester, NH

Full-time – days, some evenings

The Clinical Documentation Specialist (CDS) will be responsible for facilitating concurrent documentation of the medical record to achieve accurate and complete representation of the Severity of Illness and Risk of Mortality of the hospitalized patient, resulting in the assignment of appropriate ICD-10 codes and DRGs on the medical record. This involves extensive record review, interaction with physicians, HIM professionals and nursing staff.

The CDS will create and maintain records of the records reviewed, queries placed, and outcomes of the CDI program. Will serve as a clinical documentation resource for physicians. The CDS will place and assist the inpatient coders with query placement, query re-issue, and query follow-up with physicians regarding unanswered queries after discharge, to obtain all necessary documentation of disease states and diagnoses in the medical record.

Position Qualifications:

  • Associate Degree in Nursing, Health Information Technology or related field, or an equivalent combination of at least 5 years of training and experience in acute care inpatient clinical experience, or acute care inpatient and/or outpatient hospital coding experience that demonstrates a strong understanding of the required knowledge, skill and abilities.
  • Must have knowledge of anatomy and physiology, medical/surgical/pharmacological terminology, patient care documentation standards, ID-10CM & PCS, HCPCS and CPT codes.CCDS (ACDIS) or CDIP (AHIMA) desired; RHIT or RHIA certification preferred.
  • Excellent verbal and written communication skills; ability to work within all levels of the organization and as a part of a team and proficiency in the navigation of electronic medical records and basic windows-based computer software.

Frisbie Memorial Hospital is unique in today’s healthcare environment. Frisbie is about our people, our technology and the trust of our patients. We use the latest technology to help our dedicated staff find solutions that benefit our patients. Technology that promotes faster healing, better health, higher quality of life and in-turn, career satisfaction. We invite you to see why a career at Frisbie can be exactly what you need.

Frisbie Memorial Hospital’s ability to excel at caring for the community depends on its people. That’s why we invest in our workforce and reward employees for exceptional performance — and why we offer a comprehensive and highly competitive benefits package.

For inquiries and to apply, please contact:
Rhonda Meserve, Talent Specialist
Frisbie Memorial Hospital
11 Whitehall Road
Rochester, NH 03867
P: 603-335-8465
E:
R.Meserve@fmhospital.com

If you would like more information about Frisbie Memorial Hospital, please visit our careers site at: https://frisbiecareers.com/

Frisbie Memorial is an equal opportunity employer.