Clinical Documentation Specialist

Description
Provide concurrent review of clinical documentation in the medical record ensuring that the physician documentation supports the severity of patient illness and risk of mortality.

Responsibilities

This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.
 

• Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines. Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record. The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators; then?Queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality. ?Performs a thorough chart review to determine the most appropriate principal diagnosis of the patient.?Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet. ?Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses.?Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care.?Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. ?Maintains the ability to be flexible and prioritizes daily responsibilities. (60%)
• Uses strong and professional communication skills with providers to clarify information in the medical record. Uses appropriate and compliant querying tools (templates) to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries. (25%)
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or individually with physicians. (10%)
• Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Identifies areas of focus through report analysis. (5%)
• Experience with CDI for Peds, Neonatal, and OB. 

Qualifications
All job qualifications listed indicate the minimum level necessary to perform this job proficiently.

LEVEL OF EDUCATION

Minimum:

• Associate's Degree Nursing

Preferred:

• Bachelor?s Degree or higher in Nursing

CERTIFICATIONS, LICENSES, REGISTRATIONS
Preferred:

• Current RN License

TECHNICAL REQUIREMENTS

Minimum:

• Basic MS office skills; including Excel, Word, Outlook. Basic proficiency in computer applications.

Preferred:

• EPIC, 3M 360, 3M eMD

KNOWLEDGE, SKILLS, and ABILITIES
All knowledge, skills, and abilities listed indicate the minimum level deemed necessary to perform this job proficiently.

• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators. Up-to-date clinical knowledge.
• Ability to create and maintain strong relationships and confidently discuss clinical diagnoses. Skills in negotiation, conflict resolution, follow through and follow up. Ability to work independently in a time-oriented environment.
• The employee communicates effectively.Excellent and professional written and verbal communication skills. Ability to write concisely and effectively when communicating with providers.
• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Good organizational skills with attention to detail and accuracy. Maintains the ability to be flexible and prioritizes daily responsibilities.