Clinical Documentation Specialist

Works under the supervision of the Manager to provide support, consultation, compliance to evidence-based care, and clinical documentation practices. Facilitates and drives improvements in the clinical performance initiatives and helps to maintain regulatory compliant documentation. Performance relies on general nursing/clinical knowledge, including pathophysiology, pharmacology, regulatory requirements and ACDIS professional guidelines. Advanced communication and education to a broad audience including medical staff, patients, clinical departments in the form of specific chart reviews and broad presentation/education. Collaborates regarding clinical and coding knowledge with key stakeholders within the organization. Responsibilities include concurrent review of the clinical documentation to obtain the most accurate and complete physician documentation that appropriately supports the severity of illness, risk of mortality and proper reimbursement.

• Conducts initial and concurrent reviews of clinical documentation for all selected admissions to initiate the tracking process and document findings. Abstracts data from concurrent and retrospective charts, as well as computerized data systems using documentation, coding and query guidelines.
• Completes admission coding for swing bed and acute rehab visits. Understands reimbursement methodologies and coding guidelines for swing bed and acute rehab.
• Assigns and updates ICD-10-CM/PCS codes and working DRG for encounters, reviewing in a timely manner and documenting thoroughly in clinical documentation integrity system.
• Identifies need to clarify documentation in records and initiates communication with provider utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
• Utilizes monitoring tools to track the progress of the concurrent review program, interprets tracking information and reports findings.
• Rounds with physicians in patient rooms, identifying opportunities and providing education on clinical documentation. Provides information and education as necessary to physicians and ancillary staff. This includes participation on work teams.
• Completes second level review including mortality reviews.
• Monitors all coding and DRG changes as well as coding and query guidelines. Provide information to business/clinical partners as to the impact. Proactivity research documentation and coding guidelines to support the organization
• Provides feedback to others regarding their documentation findings on contributions to the improvement activities. Acts as mentors to caregivers to improve compliance with standards and documentation requirements.
• Participates in staff training and departmental improvement activities and uses the results of the quality of care activities to initiate change in practice. Communicates with coders to ensure that the correct DRG is assigned to each case; receives feedback as a means of continuous self-improvement
• Collaborates with other members of the interdisciplinary team to achieve accurate documentation for coding (example: rounds with physicians, attends team conference). Collaborates with physicians to writes appeal letters for clinical DRG change denials received from payers.
• Assumes responsibility for professional development by participating in workshops, conferences and/or in-services and maintains appropriate records of participation.
• Other duties as assigned

• Associate's Degree - Nursing - Required
• Bachelor's Degree - Nursing - Preferred

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting. - Required
• 1 Year - Experience in clinical documentation integrity functions - Preferred

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - State Licensure/Or Compact State Licensure in state, depending upon designated work location - Required Upon Hire
• Certified Clinical Documentation Specialist (CCDS) - Required within 2 Years Or
• Certified Documentation Improvement Practitioner (CDIP) - Required within 2 Years

• Must be able to travel between various system facilities and off-site locations as needed. - Required

Essential Technical/Motor Skills

• Input and retrieve data, speaking clearly, answering phones, precise hand\eye coordination, fine motor skills and good writing skills.
• Strong clinical skills.

Interpersonal Skills

• Must be courteous
• Work in a professional, caring manner with internal and external customers
• Have the ability to work with interruptions, and flexibility in hours and workflow, foster teamwork and promote service and quality in everything.
• Excellent communication and critical thinking skills.

Essential Physical Requirements

• Regularly required to sit, reach with hands and arms. Must have the ability to lift and/or move up to 10 pounds.

Essential Mental Abilities

• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related processes.
• Must be able to interpret patient record.
• Must function independently and have follow through skills, detail-oriented. Ability to prioritize work.

Essential Sensory Requirements

• Visual, hearing.

Exposure to Hazards

• Infection/disease exposure from patients, visitors, and co-workers.

Other Skills and Abilities