Clinical Documentation Specialist

GENERAL SUMMARY:

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation to support coding and reporting of high-quality healthcare data through independent clinical judgement and professional autonomy. Ensures the clinical documentation appropriately describes the patient's severity of illness, risk of mortality and reflects the level of service rendered.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the Bryan Health mission, vision, values, and goals and consistently demonstrates our core values.

2. *Works with clinicians, including physicians, to facilitate appropriate clinical documentation in the medical records.

3. *Provides concurrent review of the clinical documentation in the medical record and reviews the medical record with a clinical lens to identify any missing or understated diagnoses.

4. *Queries the medical staff, when necessary, through written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient conditions and treatment plan.

5. *Coordinates with Coding, HIM, Utilization Review and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

6. *Reviews documentation or coding issues with coding specialists to assign a working Diagnosis-Related Group (DRG).

7. *Educates internal customers on clinical documentation opportunities, coding and reimbursement issues.

8. *Performs a thorough chart review to determine the appropriate principal diagnosis of the patient and to identify comorbidities and complications.

9. Identifies gaps in the documentation where query is necessary. Documents appropriately within the concurrent review worksheet/template to utilize critical thinking to analyze problems, identify needs and priorities and implement effective work strategies.

10. *Improves quality, completeness and accuracy of clinical documentation.

11. *Maintains appropriate records, reconciling information with external and internal sources, where needed.

12. *Examines and provides feedback on clinical documentation opportunities, coding and reimbursement issues.

13. Attends education sessions to maintain knowledge of clinical coding guidelines, coding compliance standards and CDI Concepts

14. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

15. Participates in meetings, committees and department projects as assigned.

16. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*").

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of diagnostic testing, surgical procedures, disease process and care paths.

2. Knowledge of Inpatient Prospective Payment System (IPPS), Coding Regulations and documentation requirements.

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Knowledge of anatomy, physiology, pharmaceuticals, medical terminology, disease process and ICD-10-CM.

5. Skill in coaching and educating peers and physicians.

6. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, ancillary departments and volunteers.

7. Ability to follow policies and procedures that meet the regulatory guidelines for Clinical Documentation Integrity.

8. Ability to prioritize work demands and work with minimal supervision.

9. Ability to communicate effectively both verbally and in writing.

10. Ability to maintain confidentiality relevant to sensitive information and HIPAA guidelines.

11. Ability to meet high standards for work accuracy and productivity.

12. Ability to maintain flexibility and prioritizes daily responsibilities.

13. Ability to work independently in a time-oriented environment.

14. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of three (3) years recent clinical experience in an acute care setting required.

OR

Registered Health Information Administrator (RHIA) with Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) or equivalent experience required.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.