What are the responsibilities and job description for the Clinical Documentation Specialist position at Conway Medical Center?
Position Summary:
The Clinical Documentation Specialist (CDS) will perform concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of provider documentation. This is accomplished by medical record review and query processes.
Qualifications:
Education:
- Associate’s Degree in Nursing (ADN) required.
- Bachelor’s Degree in Nursing (BSN) preferred.
Experience
- Excellent communication and critical thinking skills.
- Computer experience required.
- Ability to work independently and meet deadlines and schedules is required.
- Knowledge of care delivery documentation systems and related medical record documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures.
- Strong broad-based clinical knowledge and understanding of pathology/physiology.
- Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred but not required.
- A minimum of three (3) years recent experience in an Acute Care setting in a clinical nursing field; inpatient facility coding; or other related healthcare field.
- General knowledge of IPPS; ICD-10 Coding; MS-DRG/APR-DRG and HCPCS coding systems preferred.
- Excellent interpersonal skills.
- Strong organization and analytical skills.
- Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint).
Licensure/Certification/Registration
- Unincumbered Nursing License in the State of South Carolina (or compact state) required (RN).
- Health Information Management with a RHIA/RHIT/CCS
- Clinical Documentation Specialist with a CCDS
Duties & Responsibilities:
- Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
- Initiates queries to the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality, comorbid conditions, length of stay and present on admission status.
- Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query practices.
- Develop and maintain supportive, collaborative relationships with providers and health care team members to include education and follow up.
- Serve as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.).
- Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
- Assign a working DRG for health care team discharge planning and CDI use.
- Maintains the ability to be flexible and prioritizes daily responsibilities.
- Completes other duties as assigned by department leadership.
