Clinical Documentation Specialist - 8 Hour Days

Job Description

Summary:
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.

Principal 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.

Department Specific Responsibilities:

Teamwork/Customer Relations Responsibilities:

• Collaborates to problem solve and make decisions to achieve desired outcomes
• Establishes effective working relationships with cross-functional team(s)
• Responds timely, effectively and appropriately to deliverables
• Shares knowledge, time and expertise to assist other members of the team
• Cultivates and maintains strong customer relationships and rapport with stakeholders and/or client groups
• Ensures practices and procedures are inclusive of interpersonal and cultural diversity
• Identifies and responds appropriately to both internal and external customer needs utilizing available resources
• Represents the company with external constituents

Qualifications

Qualifications:

Education:

• High school diploma or GED required
• Bachelor's Degree in Nursing or other advanced health care field preferred
• Foreign trained MDs will be considered

License/Certifications:

• Registered Nurse, LVN, Occupational Therapist, Physical Therapist, Physician Assistant, foreign MD license or certification in Health Information Management or Medical Coding, such as RHIT, RHIA, CDIP OR CPC, preferred
• CCDS required

Experience:

• A minimum of 3 years of experience in Acute Clinical Care, Utilization Review, Coding, or Case Management preferred
• Working knowledge of Joint Commission standards and regulatory requirements
• 2 years performing CDI reviews within an acute care facility or bedside experience required
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes preferred
• Solid computer proficiency required