Clinical Documentation Specialist
2 weeks ago
Job Description
Summary:
The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement are received for the level of services rendered to the patients.
Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Maintains positive communication with physicians, nursing and all other disciplines involved in the care of the patient. Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures. Updates DRG worksheet to reflect any changes to inpatient status/procedure/treatment and confers with the physician to finalize diagnosis. Consistently meets established productivity targets for record review. Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation. Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies. Assists in collection and organization of data for analysis by appropriate medical and hospital committees. Identifies strategies for sustained work process changes that facilitate complete accurate clinical documentation. Demonstrates competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of the members served by the department. Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served. Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities. Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties. Performs other duties as assigned.Requirements:
Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Associate’s Independent Study Course for Medical Record Technicians is required. College courses in medical terminology and anatomy and physiology preferred. Must be efficient and completely accurate in performance of coding tasks. Must be able to accurately read and decipher handwriting that is difficult to read. Handwriting of alphabet and numbers must be neat and legible. Must be able to work with speed and accuracy and with good eye-hand coordination. Must be able to operate computer terminal and other office machines. Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM/ICD-10-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC). Must be familiar with content and arrangement of the medical record. Must be familiar with the other functions in Medical Records and how they relate to the Coding function. A minimum of 5 years in area of population to be served is required. Three (3) years pervious acute hospital inpatient coding experience required. Case Management / Utilization Management and discharge planning experience preferred. Must possess a good background in medical terminology and anatomy and physiology as the fundamental of medical science. Registered Health Information Management Administrator Technician (RHIT) required Registered Health Information Management Administrator (RHIA) preferred Certified Inpatient Coding Specialist (CCDS) highly preferred; if not certified must be eligible to take one of the abovementioned exams and must obtain credentials / certifications within 12 months of hiring date.Certified Inpatient Coding Specialist (CCS) required within 12 months of hire Certified Inpatient Coding Specialist (CCS) required within 12 months of hire CDS certification preferred-
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