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Clinical Documentation Specialist

4 months ago

Tyler, United States Impresiv Health Full time
Title: Clinical Documentation Specialist

Description: The PRN Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The PRN CDS will provide support and expertise on a temporary basis through comprehensive assessment and review of inpatient medical records. The PRN CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure that reimbursement (reflecting proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.

What You Will Do:
  • Performs concurrent and retrospective reviews of the medical record utilizing evidence-based knowledge, protocols and criteria.
  • Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensuring appropriate reimbursement is received for the level of service rendered to all patients.
  • Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
  • Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
  • Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
  • Demonstrates familiarity with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS).
  • Completes initial reviews of patient records to evaluate documentation to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness.
  • Completes follow-up reviews.
  • Reviews a minimum of standard charts per day as directed.
  • Analyzes clinical information. Formulates appropriate clinical documentation clarifications to improve documentation. Queries and educates physicians and key healthcare providers regarding clinical documentation improvement.
  • In conjunction with CDI leadership, tracks response to clinical documentation and trends in CDI metrics.
  • Maintains and enhances current medical, coding and CDI knowledge by participating in continuing education offerings.
  • Consistently meets established productivity targets for record review.
  • Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
  • Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
  • Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.

You'll Be Successful If:
  • Strong clinical knowledge and understanding of pathology/physiology of disease processes
  • Excellent interpersonal skills with the ability to build relationships with physicians, nurses, and staff, so that you can provide training and education.
  • Ability to work independently and manage goal productivity while remaining efficient and accurate in performance.
  • Ability to be able to read and decipher handwriting that is unclear and difficult to read.
  • Working knowledge of MS-DRG and APR-DRG
  • Familiarity with other functions in Medical Records and how they relate to coding functions.

What You Will Bring:
  • Degree in one of the following from an accredited program: Associates or Bachelors Degree in Nursing, Associates or Bachelors Degree in Health Information Management
  • 3+ years of experience as a Clinical Documentation Specialist
  • 3+ years of acute hospital inpatient coding experience
  • Currently licensed or certified in on of the following: RN for state of practice, RHIT, Certified Coding Specialist, RHIA
  • Certified Clinical Documentation Specialist preferred

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv