Clinical Documentation Spec

The Clinical Documentation Specialist will facilitate modifications to clinical documentation, through concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity. The specialist shall concurrently review and evaluate selected patient’s medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.
 

Principal Accountabilities:


1. Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies 
2. Creates job aids and queries in support of training initiatives 
3. Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting 
4. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart 
5. Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding 
6. Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings 
7. Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured 
8. Serves as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts 
9. Performs other relevant duties as assigned

Required: 
1. Associates Degree in Nursing; 
2. Bachelor of Science Nursing degree preferred 
3. 5 years of Med/Surg acute care clinical experience required, experience in ICU strongly preferred 
4. Registered licensed nurse (RN) required 
5. Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required 
6. One-two years experience as CDI Specialists preferred 
7. 3M Coding and Reimbursement and/or 360 Encompass preferred 
8. Working knowledge of ICD-10 preferred 
9. Epic experience preferred 

Preferred: 
1. Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers. 
2. Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations. 
3. Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.