Clinical Documentation Specialist

1 month ago

Newton, Massachusetts, United States Mass General Brigham Full time

Job Summary

The Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicare and Medicaid (CMS) regulations and guidelines and to expedite appropriate reimbursement.

Key Responsibilities

  • Carries out concurrent medical record reviews for identified payer populations as directed on admission and throughout hospitalization and for clinical documentation improvement opportunities in the acute care setting.
  • Reviews physician documentation related to the current treatment plan and past medical history and identifies documentation gaps /opportunities on a daily basis and /or as needed.
  • Ensures that the clinical documentation is complete, accurate and compliant with the Center for Medicare and Medicaid Services regulations and that it reflects the level of service rendered.
  • Assists in the development of diagnosis/DRG specific queries to assist physicians with documentation.
  • Serves as a resource for physicians to help link ICD-9 and 10 CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment.
  • Resolves inconsistent, conflicting and/or ambiguous documentation through the query process.
  • Assigns a working DRG based on coding guidelines/regulations issued by AHA (Coding Clinic), CMS, and AHIMA.
  • Interprets clinical information in medical record, evaluates medications, vital signs, surgical outcomes, etc. to identify potential diagnoses.
  • Identifies physician documentation issues/omissions/discrepancies and communicates with physicians in person, via the telephone, e-mail and/or through written physician queries about opportunities for more accurate documentation to achieve department standards for acceptable physician response rates.
  • Helps to ensure documentation reflects the patient's past medical history, acuity and intensity of services provided.
  • Collaborates with HIM coding, care coordination, quality staff, physicians and patient accounts regarding coding deficiencies and/or denials that may be attributed to documentation issues.
  • Utilizes the 3M grouping software to determine the working DRG and communicate with the HIM coding staff.
  • Monitors and evaluates the effectiveness of concurrent or retrospective chart review and query outcomes at designated intervals in collaboration with leadership and coding staff.
  • Enters data into a designated software program for CDI that is reviewed by coding staff to facilitate ongoing feedback to the Clinical Documentation Improvement (CDI) team.
  • Possesses conflict management skills and has the ability to identify and solve problems and participate in remediation efforts.
  • Carries out other duties as assigned or requested.

Quality Assessment/Performance Improvement

  • Identifies quality of care issues; analyzes, documents, and reports appropriately in accordance with Hospital and departmental policies and procedures, including but not limited to generic and specific occurrence screening, patient incidents, adverse drug reactions, and risk management issues.
  • Conducts QA/PI activities as directed
  • Provides reports/findings to medical staff and /or other hospital committees.
  • Assists with data collection and analysis as necessary.

Professional Development

  • Maintains professional competency by keeping abreast of new coding issues and guidelines, attending applicable educational programs and meetings, and reviewing professional coding literature.
  • Participates in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels.
  • Seeks voluntary membership with a national CDI group such as ACDIS and participates in the resources including conference calls, blogs, newsletter, etc.

Qualifications

  • Graduate of an accredited school of nursing, BSN preferred
  • Licensure as a Registered Nurse in the Commonwealth of Massachusetts with minimum of 5 years of recent acute med surg or critical care experience.
  • 3.3-5 years of clinical documentation/coding experience required.
  • Knowledge of relevant Medicare, federal and state health-care regulations and related accreditation requirements; knowledge of insurance implications on coding and InterQual or Milliman criteria.
  • Knowledge of job-related related continued education and professional development in the last two years
  • Certification as a Clinical Documentation Specialist preferred
  • Knowledge of coding/classification systems appropriate for inpatient DRG prospective payment system.
  • Ability to communicate and work within a multidisciplinary environment.

Skills and Abilities

  • Organizational skills with detail-oriented approach.
  • Ability to work independently and establish an effective relationship with physicians.
  • Autonomy in decision making using sound judgment
  • Ability to seek out and identify resources to problem solve issues.
  • Excellent literate and able to enter data as required.
  • Knowledge of JCAHO requirements and federal and state guidelines applicable to health record completeness and patient privacy.
  • Ability to work in a team.
  • Ability to accept constructive feedback.

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