Clinical Documentation Specialist
3 days ago
We are seeking a highly skilled Clinical Documentation Specialist RN to join our team at Hackensack Meridian Health. The successful candidate will be responsible for facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation for assigned hospitals. This includes obtaining and promoting appropriate clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers.
Key Responsibilities
- Facilitate accurate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
- Perform admission reviews for specific patient populations using clinical documentation guidelines.
- Assist in the medical screening process by documenting appropriateness of patient admission and working DRG & LOS information on worksheets and computer systems.
- Extensively review all physician and clinical documentation, lab results, diagnostic information, and treatment plans to capture appropriate information on 3M 360 worksheets.
- Utilize clinical skills to identify documentation opportunities that reflect severity of illness, acuity, and resource consumption.
- Verbally communicate with physicians to ensure documentation opportunities are clarified.
- Communicate with ancillary personnel to clarify potential documentation opportunities.
- Update DRG worksheets to reflect any changes in patient status, procedures, treatments, and confer with physicians to finalize diagnoses.
- Review medical records every 24-48 hours as appropriate.
- Update 3M 360 worksheets to reflect additional physician documentation, lab findings, diagnostic test results, and treatment as appropriate.
- Update 3M 360 worksheets to reflect any changes in DRG and/or APR assignment.
- Communicate with physicians to ensure that requests for documentation have been noted.
- Confer with physicians to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications, and procedures.
- Conduct follow-up reviews of clinical documentation to ensure issues discussed and clarified with physicians have been documented in the patient's chart.
- Document and analyze data and report instances of inappropriate patient care, discharge delays, etc. to leaders of Health Information.
- Follow established department processes for follow-up reviews and physician communication.
- Review clinical issues with coding staff to assign working DRG using software.
- Collaborate with coding staff as needed to determine appropriate DRG and required documentation.
- Utilize coding staff knowledge of Coding Clinics that impact CDMP.
- Provide clinical expertise and references to the coding staff.
- Follow established guidelines for reconciling final coded DRG with the CDMP DRG assigned at the time of discharge.
- Stay current with and conduct ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, and nursing and allied health professionals.
- Track and trend program compliance.
- Attend and participate in weekly educational conferences.
- Participate in concurrent performance improvement activities and ongoing MR review activities.
- Review 3M 360 tracking data in conjunction with established benchmarks.
- Provide an overview of CDMP to new staff, allied health professionals, and physicians.
- Maintain positive and open communications with physicians, interdisciplinary care team members, coding staff, Coding Compliance Manager, Department Director, and Emergency Trauma Dept.
- Screen ED inpatient admissions and observations determining the necessity and appropriateness of hospitalizations using facility criteria.
- Recommend admission or observation disposition to the ED physician in accordance with the screening.
- Collaborate with admitting physicians to place patients in appropriate status.
- CDS must attend/participate in Multidisciplinary Rounds (MDR) of their designated/assigned unit.
- Communicate with physicians when screening criteria is not met for inpatient and requests additional documentation if appropriate.
- Review concurrent and post-coding pre-billing medical records for completeness and accuracy for severity of illness (SOI) using the Compliant Documentation Management Program (CDMP) documentation strategies.
- Initiate 3M 360 severity worksheets for inpatients.
- Request documentation clarification as appropriate for SOI.
- Assess all appropriate admissions for POA documentation of: pressure ulcers, vascular-catheter associated infections, indwelling urinary catheter associated infections, surgical site infections, DVT, pulmonary embolus, and risk for falls.
- Document assessments in the medical record.
- Initiate core measure reviews as indicated for specific clinical topics: AMI, pneumonia, heart failure, stroke, severe sepsis & septic shock, and patient safety indicators.
- Provide ongoing education to ED and admitting physicians regarding appropriate documentation and criteria for admission, observation, and level of care to comply with federal and state mandates.
- Maintain liaison with the inpatient case manager and communicate necessary follow-up.
- Maintain liaison with inpatient CDS and provide report summaries.
- Perform other duties and/or projects as assigned.
- Adhere to HMH Organizational competencies and standards of behavior.
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