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Clinical Documentation Specialist

1 month ago

Louisville, Kentucky, United States UofL Health Full time
Job Summary

The Clinical Documentation Specialist will develop and maintain relationships with physicians and medical staff while serving as a liaison between the CDI Specialists, HIM, and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data. This role will provide education and assistance to physicians and medical staff regarding documentation compliance questions, CDI physician queries, and clinical preciseness that truly reflects the patient's care and treatment course.

Responsibilities
  1. Finalize unanswered open queries between CDI specialists and physicians.
  2. Complete initial medical record reviews of all inpatient patient accounts within 24-48 hours of admission to evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
  3. Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness, and initiate a review worksheet.
  4. Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
  5. Spend a minimum of 50% of the workday in the hospital as a physician resource, developing physician and medical staff relationships.
  6. Provide ongoing physician and medical staff education regarding documentation, queries, coding guidelines, clinical terminology, and coding updates to improve their understanding of severity, acuity, risk of mortality, and DRG assignment.
  7. Collaborate with the Quality department and physicians to identify and resolve documentation patterns and discrepancies.
  8. Provide new medical staff orientation regarding clinical documentation and physician documentation responsibilities.
  9. Develop and provide in coordination with the CDI manager current documentation tip sheets to enhance accurate and complete documentation and coding.
  10. Recommend changes to documentation templates and physician queries based on coding changes, regulatory modifications, and quality review findings.
  11. Coordinate training and education for Coding Specialists and CDI staff when trends are identified.
  12. Provide on-call service for physician and medical staff query questions and education.
  13. Refer potential and identified HACs, PSIs, and preventable hospital HARMs to the Quality department.
  14. Maintain CDI department database and spreadsheets on medical staff education regarding documentation, queries, coding guidelines, medical terminology, and coding updates.
  15. Formulate clinically, compliant, and credible physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
  16. Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient.
  17. Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.
  18. Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements.
  19. Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge.
  20. Communicate/completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution with appropriate leadership.
  21. Remain abreast and current on training of new hires and ongoing CDIS professional staff development as well as participate in CDI-related continuing education activities to maintain certifications and licensures.
  22. Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
  23. Identify patterns, trends, variances, and opportunities to improve documentation review processes.
  24. Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff.
  25. Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.