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Clinical Documentation Specialist
3 weeks ago
Primary Responsibilities:
- Review outpatient medical records for documentation opportunities and problem list accuracy. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
- Partners with providers and administrative staff to support Risk Adjustment initiatives. Leverages technology to identify gaps in Risk recapture
- Uses EHR tools to support risk-adjustment clinical documentation integrity initiatives in collaboration with
- Educates staff and providers on documentation principles and assists in communicating program metrics through dashboards and various reports.
- Attend multidisciplinary patient rounds with care team
- Communicate with care team regarding documentation opportunities and ICD 10 specificity-verbal or written clarifications and track this data in electronic repository identified for CDI. Verify the response from care team to clarification of diagnosis
- In collaboration with physician leadership, designs and implements specific tools, templates and educational programs to support medical record physician documentation
- Identify and arrange education for new providers soon after onboarding- develop educational offerings for new providers
- Identify trends/opportunities for improvement in documentation habits of service line and report that information to the attending group in education session
- Expert knowledge of EHR use and tools available for clarification presentation and tracking
- Maintain expert knowledge of current changes of ICD 10 requirements and HEDIS measures and educate providers to needed changes in documentation
- Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation.
- Maintain open communication with coding staff, CDS and CDI physician liaison to accurately reflect the diagnoses
- Actively seek new opportunities to review records and offer documentation education and advice-inpatient, ED, outpatient specialty and primary care clinics
- Active involvement in post coding review of charts for accurate reflection of diagnosis coding
Requirements:
- Must have at least 5 years pediatric nursing experience.
- BSN required
- CDI certification and/or coding certification preferred
- Licensed registered nurse active and unrestricted in the State of Delaware
- Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes
- Registered Nurse preferably with Pediatric nursing and/or CDI experience
- Minimum of 5 years' experience in pediatric nursing
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