Clinical Documentation Specialist

Description

The Clinical Documentation Specialist facilitates updates to clinical documentation by collaborating with physicians and clinicians to accurately reflect severity, complications, and co-morbidities. Reviews and evaluates
patient records for quality and completeness. Educates physicians, nonphysician clinicians, and coding staff on documentation, coding, reimbursement, and quality improvement opportunities. Identifies documentation-related quality of care issues and resolves them appropriately.


Principal Accountabilities:
1.   Review medical records to assign accurate DRG
2.   Perform initial, concurrent, and retrospective reviews
3.   Complete initial review within 24–48 hours of admission
4.   Ensure SOI, ROM, and comorbidities are documented
5.   Collaborate with coding staff for accurate documentation
6.   Educate staff on documentation and coding guidelines
7.   Train new C DS specialists, coders, physicians, residents
8.   Share knowledge for ongoing team learning
9.   Maintain compliance in chart reviews and queries
10. Support quality measures and system initiatives

Qualifications

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.