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Job Title: Clinical Documentation Info Spec.

Company: MidHudson Regional Hospital

City/State: Poughkeepsie, NY

Category: Clerical/Administrative Support

Department: Health Info Mgmt

Position: Full Time

Hours: M-F 9-5

Shift: Day

Req #: 23855

Job Details:

The CDIS will focus on improving the clinic clarity of the health record. Will become an important vehicle bridging the gap between the clinical documentation contained in the health record and the resulting clinical and claims data utilized for reimbursement, research, and outcome management.

Experience:

Two (2) years coding experience or five (5) years of nursing experience preferred. Strong clinical skills, ability to interpret clinical indicators found in tests results, recognize/understand disease processes, and identify therapeutic diagnostic orders that demonstrate attention to undocumented conditions. Education and Training: Associate of Science in nursing or Bachelor of Science in Nursing (preferred). License, Certification and Registration: Current NYS Registered Nurse, clinical certification in association with coding. Other Requirements: Knowledge of 3M coding software, and Meditech application.

About Us:

MidHudson Regional Hospital

MidHudson Regional Hospital in Poughkeepsie, NY, is home to the mid-Hudson Valley’s most advanced healthcare services. This 243-bed facility cares for more than 10,000 inpatients annually while performing an additional 325,000 outpatient procedures each year. MidHudson Regional Hospital operates the area’s only Level II trauma center, is home to the Redl Center for Cancer Care and Center for Robotic Surgery, and is a destination hospital for patients with serious illnesses and injuries.