Clinical Documentation Specialist II, Full-Time, Days

Inspire health. Serve with compassion. Be the difference.

Job Summary

Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment. Serves as second level reviewer, education resource, and preceptor. Participates in education to providers, CDI/Coding teams, and other departments.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose:  Inspire health.  Serve with compassion.  Be the difference.

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation.

• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.

• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.

• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.

• Stays current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.

• Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)

• Assigns a working DRG for health care team discharge planning and CDI use

• Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification. 

• Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Bachelor's degree - Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.

• Experience - Four (4) years adult medical/surgical/critical care/ER/PACU nursing coding or related experience. Two (2) years clinical documentation improvement experience.

In Lieu Of

• In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP/CCDS/CDIP

Required Certifications, Registrations, Licenses

• One of the following certifications: RHIA, RHIT, CCS, CIC or holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

• CCDS/CDIP

Knowledge, Skills and Abilities

• Computer skills

• Communication skills with the ability to interact with providers

• Knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70017540 Clinical Documentation Integrity

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.