What are the responsibilities and job description for the Clinical Documentation Specialist position at Brockton Hospital?

Signature Healthcare is Southeastern Massachusetts premier local provider of quality, personalized medical services. We are comprised of the award-winning not-for-profit Signature Healthcare Brockton Hospital; Signature Medical Group (SMG), a multi-specialty physician group of more than 150 physicians practicing in 18 ambulatory locations. We believe our distinctive Signature Healthcare team approach is the way healthcare should be : medical professionals across many locations communicating and collaborating, taking advantage of technologies and resources to make a difference in the lives and health of our patients.

Position Summary :

The CDS works collaboratively with Coding, Medicine, Nursing, Case Management, the Quality Department and ancillary staffs to perform concurrent analytical review of the medical record to ensure an accurate representation of the patients severity of illness. The goal of the position is to improv e documentation of all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement .

Location : West Center St, West Bridgewater

Department : BH Health Informatics

This is a full-time 40 hour / week position

Responsibilities :

Ability to learn / develop the skills necessary to perform CDMP
Performs a ccurate and timely record review.
Formulate s clinically credible documentation clarifications .
Effective ly and appropriate ly communicat es with physicians .
Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rende red to all Medicare patients (non-risk products).
Timely follow up on all cases especially those with clinical documentation clarifications .
Participate in Task Force Meetings .
Manage s multiple priorities .
Communicates with HIM staff and resolves discrepancies .
Accurate input of data into CDMP Trak .
Ensures the accuracy and completeness of clinical information used for measur ing and reporting physician outcomes.
Processes CORE data.
Educates all members of the patient care team on an ongoing basis.
Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

1 . Commits to recognize and respect cultural diversity for all cu stomers (internal and external).

2 . Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed .

P erform s o ther duties as assigned

BASIC KNOWLEDGE / SKILLS / APTITUDE / EXPERIENCE :

Knowledge of pathophysiology and disease process; Medicare Part A and B and knowledge of the regulatory environment.

Understanding and ability to communicate the differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

Organizational, analytical, writing and interpersonal skills.

Dependable, self directed and pleasant; proficiency in organization & planning.

Critical thinking, problem solving and deductive reasoning skills.

Ability to evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation for in-patient encounters that impact the code selection and resulting DRG groups & payment.

Knowledge of regulatory environment.

Understand and support CDMP documentation strategies (upon completion of training).

Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments.

Must have excellent verbal / written presentation skills and the ability to motivate and communicate with other health care professionals.

Must have ability to function effectively, delivering accurate data analyses while working under minimal supervision.

Time management skills in order to handle numerous requests simultaneously is required.

Knowledge of disease processes & procedures.

Strong clinical knowledge of anatomy / physiology / pathology. Proficiency in organization & planning. Proficiency in data analysis such as, but not limited to, database and spreadsheet analysis, presentation programs & Internet searching.

Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization may exist.

Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Must be able to reasonably make appropriate judgment in communications and actions with patients, physicians, other associates, outside agencies, and vendors.

Education / Experience / Licenses / Technical / Other :

Education : High school diploma or equivalent required . Bachelor's Degree in Nursing required. Must have current license from Commonwealth of Massachusetts to practice as a Registered Nurse.

Experience (Type & Length) : Minimum of five years clinical experience in an acute care facility required . Recent hospital experience preferably in critical care areas or strong medical / surgical. Recent hospital experience preferably ICU, CCU, Emergency Room or strong Med / Surg acute care background . Prior experience with computer applications, Windows based software programs and electronic health record required .

Certification / Licensure :

Software / Hardware :

Other :

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Clinical Documentation Specialist

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