Clinical Documentation Specialist
5 days ago
We are seeking a highly skilled Clinical Documentation Specialist to join our team at Eisenhower Health. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical records.
Job Summary:The Clinical Documentation Specialist will work closely with physicians, caregivers, and coding staff to achieve timely, accurate, and complete documentation. This includes providing on-going physician/provider education and consultation to improve the accuracy, completeness, specificity, and compliance of the in-patient acute care Medical Record.
Key Responsibilities:- Conduct concurrent review of medical records to identify areas of documentation requiring clarification of comorbidities, presence of complications, and opportunities to improve documentation from the physician to accurately assign the best DRG.
- Compile data in Midas and maintain monthly and quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance.
- Track and report financial and statistical data in designated system.
- Prepare monthly and quarterly reports for Director of Case Management.
- Communicate with and work collaboratively with coding personnel to determine outcomes regarding severity/complexity and to assure all opportunities have been pursued before patients' discharge from acute care setting.
- Educate physicians and staff on Query tool as it relates to quality of documentation in the medical record.
- Review all defined medical records to identify laboratory, radiology, cardiac & pulmonary information and procedures pertinent to the patient's care that is not clearly documented in the medical record.
- Analyze deficiencies and educate physicians in need for appropriate documentation to capture the complexity of care and the severity of illness.
- Implement tracking systems to measure the effectiveness of education.
- Develop and track, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation.
- Interface with physician champion regarding educational opportunities for specific documentation with physicians identified as needed additional education.
- Develop and update pertinent policies and procedures and processes in collaboration with the Director of Case Management.
- Maintain compliance to HIPAA and all other regulations related to patient confidentiality.
- Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Improvement process and outcomes.
- Communicate with team members and participate in appropriate committees to report outcome information.
- Collaborate with the Utilization Management Specialist when continued stay or level of care issues are identified.
- Assist the HIM department in facilitation of the physician query process after patient discharge.
- Perform special projects and other duties as directed.
- Bachelor's degree in Nursing (BSN) or Master's degree in Nursing (MSN) or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012.
- Active California RN license.
- Minimum of 5 years recent clinical nursing experience in an acute care setting.
- Preferred: CCS, RHIT, ICD-10 AHIMA training certification or equivalent.
This position requires a high level of accuracy, attention to detail, and strong communication skills. The ideal candidate will be able to work independently and as part of a team, with a strong commitment to delivering high-quality patient care.
Eisenhower Health is an equal opportunity employer and welcomes applications from diverse candidates. We offer a competitive salary and benefits package, as well as opportunities for professional growth and development.
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