Clinical Documentation Specialist - 8 Hour Days

Our take on this role

About this role

Review electronic health records for gaps in physician documentation and work with providers to clarify diagnoses and treatment. Create trend reports, mentor documentation specialists, and provide feedback to leadership.

What could you bring from clinical work?

• Nurses: Reviewing bedside patients' diagnoses, acuity, and treatment could help you identify documentation gaps and develop physician queries.

Full job description from Cedars-Sinai

The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.

Responsibilities

• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement.

Qualifications

Education

• High School Diploma/GED - minimum
• Assoc. Degree/College Diploma Clinical Degree – Nursing, Health Information or Foreign Trained Medical graduate. - preferred

Experience

• 2 years Performing CDI reviews within an acute care facility or bedside experience - minimum
• 3 years Utilization review, coding or case management experience - preferred

Licenses and Certifications

• - Upon Hire minimum -OR- Certified Clinical Documentation Specialist (CCDS)
• RN State License - Upon Hire minimum -OR- (Does not need to be CA)
• Registerd Health Info Admin - Upon Hire minimum -OR- (RHIA)
• - Upon Hire minimum -OR- Clinical Documentation Integrity Practitioner (CDIP)