Location: Rochester, NY
Cap-Exempt H-1B Position — No lottery required
**SUMMARY** The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams. **STATUS: Full-time** **LOCATION: Remote** **DEPARTMENT: Clinical Documentation** **SCHEDULE: Day shift** **ATTRIBUTES** - Ability to learn/develop the skills necessary to perform the CDS role - Organizational, analytical, writing and interpersonal skills - Dependable, self-directed and pleasant - Critical thinking, problem solving and deductive reasoning skills - Knowledge of Pathophysiology and Disease Process - Basic Computer skills – familiarity with Windows based software programs - Knowledge of regulatory environment - Understand and support CDS documentation strategies (upon completion of training) - Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training) - Knowledge of Core Measure and Patient Safety Indicators (upon completion of training) - For Skilled Nursing Facility Only: a. Understand Medicare Part A guidelines b. Understand the current FY SNF PPS Final Rule c. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings d. Understand the MDS Resident Assessment Instrument (RAI) Manual e. Ability to use the CMS PDPM Calculator Tool Minimum Qualifications: - 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU. - Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD. - Previous CDS experience preferred - For Skilled Nursing Facility Only: a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility b. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, N