Clinical Documentation Spec

Responsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding.Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

Principal Accountabilities:

 

• 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 
• Creates job aids and queries in support of training initiatives 
• Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting 
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart 
• Reviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding 
• Discusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings 
• Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured 
• 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 
• Performs other relevant duties as assigned

Required: 
 

• Bachelor of Science Nursing degree preferred
• Associates Degree in Nursing minimum required
• 5 years of Med/Surg acute care clinical experience required, experience in ICU strongly preferred 
• Registered licensed nurse (RN) required 
• Strong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias required 
• One-two years experience as CDI Specialists preferred 
• 3M Coding and Reimbursement and/or 360 Encompass preferred 
• Working knowledge of ICD-10 preferred 
• Epic experience preferred
  
  Preferred: 
   
• Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers. 
• Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations. 
• Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.

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