Clinical Documentation Specialist
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• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement. Qualifications Education
• High School Diploma/GED
- minimum
• Assoc. Degree/College Diploma Clinical Degree – Nursing, Health Information or Foreign Trained Medical graduate.
- preferred Experience
• 2 years Performing CDI reviews within an acute care facility or bedside experience
- minimum
• 3 years Utilization review, coding or case management experience
- preferred Licenses and Certifications
•
- Upon Hire minimum -OR
- Certified Clinical Documentation Specialist (CCDS)
• RN State License
- Upon Hire minimum -OR
- (Does not need to be CA)
• Registerd Health Info Admin
- Upon Hire minimum -OR
- (RHIA)
•
- Upon Hire minimum -OR
- Clinical Documentation Integrity Practitioner (CDIP)
-
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