Location:

Altru Health System

PO Box 6002

Grand Forks, ND 58201

Summary:

The Clinical Documentation Specialist (CDS) is responsible for performing concurrent chart reviews to ensure that Altru Health System provides a complete and accurate medical record for all selected hospital inpatients. The CDS seeks to ensure that treatment plans, severity of illness, and all care rendered is appropriately and accurately reflected through the clinical documentation provided by physicians. This is to ensure that subsequent coding and billing will accurately reflect severity of illness and the services and care rendered for each patient. The CDS ensures reports accurately portray the care given to patients at Altru Hospital.

Essential Job Functions:

• Performs data analysis to monitor opportunities for and success of improving documentation, including data that supports Altru’s case mix index, DRG Pairs with CCs, secondary diagnosis capture rate, severity of illness, and mortality rate.

• Performs concurrent patient record review process for inpatients admissions to monitor for documentation opportunities from admission to discharge. Identifies when documentation clarification is needed, initiates communication with physician to capture the documentation that accurately reflects care rendered, severity of illness and risk of mortality.

• Assists in the development, preparation, and reporting of performance measures to Medical and coding staff for continuous improvement

• Follows up on the documentation queries to seek physician and coding compliance. Provides information and education as necessary to physicians and staff to obtain responses from documentation queries.

• Provides education to physicians to increase their ability to understand documentation guidelines that affect coding and profiling, including new physician orientation and targeted physician specialties.

• Demonstrates a working knowledge of Medicare reimbursement and coding structures and guidelines. Collaborates with the coding professionals to seek verification when necessary and enhance own knowledge.

• Performs other duties as assigned or needed to meet the needs of the department/organization.

Certifications

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources

Notes

• Temporary RN license accepted prior to start.

• Must hold an unencumbered nursing license  prior to start.

Physical Demands :

• Sit: Continuously (67-100%)

• Stand: Occasionally (5-33%)

• Walk: Occasionally (5-33%)

• Stoop/Bend: Occasionally (5-33%)

• Reach: Frequently (34-66%)

• Crawl: Not Applicable

• Squat/Crouch/Kneel: Occasionally (5-33%)

• Twist: Occasionally (5-33%)

• Handle/Finger/Feel: Continuously (67-100%)

• See: Continuously (67-100%)

• Hear: Continuously (67-100%)

Weight Demands:

• Lift -Floor to Waist Level: Sedentary (<10 pounds)

• Carry: Sedentary (<10 pounds)

• Push/Pull: Sedentary (<10 pounds)

• Slide/Transfer: Not Applicable

Working Conditions:

• Indoor: Continuously (67-100%)

• Outdoor: Not Applicable

• Extreme Temperature: Not Applicable

Driving Requirement Definitions:

• Professional Drivers: Persons who drive as their main responsibility OR transport passengers or hazardous materials.
• Frequent Drivers: Persons whose main responsibility is not driving, but drive daily or almost daily.
• Occasional Drivers: Persons who drive from once per month to as frequently as once per week.
• Infrequent Drivers: Persons who are generally not expected to drive.

Driving Requirement for this position:

Infrequent Driver

Reference ID: R5198