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Clinical Documentation Specialist
5 months ago
Summary:
The Clinical Documentation Specialist (CDS) position isresponsible for facilitating improvement in the overall quality andcompleteness of the medical record documentation. The CDS willprovide support and expertise through comprehensive assessment andreview of inpatient medical records. The CDS will facilitateaccurate DRG assignment and obtain appropriate documentationthrough extensive interaction with physicians, patient caregiversand health information management coding staff to ensure thatreimbursement are received for the level of services rendered tothe patients.
- Analyzes clinicalstatus of patient, current treatment plan and past medical historyand identifies potential gaps in physiciandocumentation.
- Communicates with attendingphysician either verbally or through written methodology tovalidate observations and suggest additional and/or more specificdocumentation.
- Maintains positivecommunication with physicians, nursing and all other disciplinesinvolved in the care of the patient.
- Worksclosely with HIM Coding staff to assure documentation of dischargediagnosis and any co-existing co-morbidities are a completereflection of the patient’s clinical status andcare.
- Maintains an electronic DRG worksheet toassist coders on identifying all documented diagnosis andprocedures.
- Updates DRG worksheet to reflectany changes to inpatient status/procedure/treatment and conferswith the physician to finalize diagnosis.
- Consistently meets established productivity targets for recordreview.
- Designs and implements incollaboration with physician leadership specific tools to supportmedical record physician documentation.
- Develops and implements plans for both formal and informaleducation of physician, nursing, and other clinical staff onclinical documentation opportunities, coding and reimbursement aswell as performance improvement methodologies.
- Assists in collection and organization of data for analysis byappropriate medical and hospital committees.
- Identifies strategies for sustained work process changes thatfacilitate complete accurate clinicaldocumentation.
- Demonstrates competence toperform assigned responsibilities in a manner that meets thepopulation-specific and developmental needs of the members servedby the department.
- Appropriately adaptsassigned assessment, treatment, and/or service methods toaccommodate the unique physical, psychosocial, cultural,age-specific and other developmental needs of each memberserved.
- Takes personal responsibility toensure compliance with all policies, procedures and standards aspromulgated by state and federal agencies, the hospital, and otherregulatory entities.
- Performs all duties in amanner that protects the confidentiality of the patient and doesnot solicit or disclose any confidential information unless it isnecessary in the performance of assigned jobduties.
- Performs other duties asassigned.
Requirements:
- Registered Health Information ManagementAdministrator (RHIA) or Technician (RHIT) graduate of an approvedcollege program for Health Information Management or graduate ofthe American Medical Record Associate’s Independent Study Coursefor Medical Record Technicians is required.
- College courses in medical terminology and anatomy and physiologypreferred.
- Must be efficient and completelyaccurate in performance of coding tasks.
- Mustbe able to accurately read and decipher handwriting that isdifficult to read.
- Handwriting of alphabet andnumbers must be neat and legible.
- Must be ableto work with speed and accuracy and with good eye-handcoordination.
- Must be able to operate computerterminal and other office machines.
- Must beknowledgeable of the application of the InternationalClassification of Diseases and Operations, Ninth Revision, ClinicalModification, (ICD-9-CM/ICD-10-CM), and Current ProceduralTerminology (CPT), Diagnosis Related Groups (DRG) and AmbulatoryPayment Classifications (APC).
- Must befamiliar with content and arrangement of the medicalrecord.
- Must be familiar with the otherfunctions in Medical Records and how they relate to the Codingfunction.
- A minimum of 5 years in area ofpopulation to be served is required.
- Three (3)years pervious acute hospital inpatient coding experiencerequired.
- Case Management / UtilizationManagement and discharge planning experiencepreferred.
- Must possess a good background inmedical terminology and anatomy and physiology as the fundamentalof medical science.
- Registered HealthInformation Management Administrator Technician (RHIT)required
- Registered Health InformationManagement Administrator (RHIA)preferred
- Certified Inpatient Coding Specialist(CCDS) highly preferred; if not certified must be eligible to takeone of the abovementioned exams and must obtain credentials /certifications within 12 months of hiring date. Certified InpatientCoding Specialist (CCS) required within 12 months ofhire
- Certified Inpatient Coding Specialist(CCS) required within 12 months of hire
- CDScertification preferred
Work Type:
Per Diem AsNeeded
