Clinical Documentation Specialist - FT - Days - Cl Docu Integ Care

DHR Health - US:TX:Edinburg - Days

Summary:

FLSA STATUS: Exempt Non-Exempt

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

The role of Clinical Documentation Specialist of Clinical Documentation Improvement Department (CDI) works closely with the Director of CDI in addition to the other clinical documentation specialists, medical and coding staff in support of excellence in patient information documented in the medical record.

Primary purpose of this role is to provide oversite of the medical record that ensures care, and treatments are documented in support of patient care and accurate DRG assignment. The goal being to accurately define coding and documentation specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided.

The role of Clinical Documentation Specialist of CDI will ensure the specialists review thorough and proper documentation during the patient’s stay. The Clinical Documentation Specialist of CDI will be accountable for the concurrent review of medical records to track documentation supporting the severity of the illness and resources utilized.

This position will use existing clinical knowledge from previous training to impart the values of clinical documentation across the various DHR Health departments. This role will require utilize the candidate’s previous clinical experience in a hospital setting to leverage knowledge of clinical medicine in regards to the proper documentation needed on a daily basis. The role will require both onsite and off-site completion of daily job requirements. This position may require travel to facilities (Cameron County and Starr County) outside the DHR main campus which is required to oversee operations of clinical documentation in facilities working in partnership with DHR.

POSITION EDUCATION/ QUALIFICATIONS:

• Medical graduate (M.D)/ Doctor of Osteopathy (D.O), Registered Nurse (R.N) or similar required or GED/High School Diploma and 3-5 years’ experience as a coder.

• Proficiency in written and spoken English

• CCS and/or CCA Exam certification within 1 year of employment or CCDS Exam certification within 1 year of employment.

• Able to meet the requirements for CCS and/or CCA Exam requirements either based on experience or education as detailed on the AHIMA or the CCDS Exam requirements as detailed on the ACDIS website.

JOB KNOWLEDGE/EXPERIENCE:

• Minimum 1 year clinical experience in acute care setting

• Knowledge of EMR and related medical record documents, coding and documentation.

• Knowledge of disease process and pathology amongst various patient populations

• Knowledge of treatment modalities for disease process and pathologies

• Strong understanding of anatomy, pathology, pharmacology and physiology of disease process.

• Excellent written, verbal communication skills and critical thinking skills.

• Able to work with teams and independently.

Responsibilities:

POSITION RESPONSIBILITIES:

• Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.

• Reviews all clinical documentation for improvement and/or quality opportunities.

• Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis

• Provide education to physicians and other clinicians on compliant documentation practices to support medical necessity, severity, reimbursement and continuity of patient care. Acts as an effective change agent and educator for physicians and allied health staff.

• Serves as a clinical resource to the coding staff when coders require clinical interpretation to determine appropriate code assignment.

• The Clinical Documentation Specialist facilitates clarification to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The Clinical Documentation Specialist will:

• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.

• Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures

• Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness

• Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.

• Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team

• Gather and analyze information pertinent to documentation findings and outcomes.

• Supports development of templates, databases and other tools to support accurate documentation. Provides reports to manager as requested. Maintains a strong knowledge of DRG methodology, severity of illness/risk of mortality statistics, and coding guidelines.

• Possesses strong understanding of the requirements for clinical coding and billing according to the rules for Medicare, Medicaid, and commercial health plans.

Other information:

LINES OF REPSONSIBILITIES:

(Chain-of-command)

1. Director 2. Chief Financial Officer

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC:

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA):

A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:

B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes: HIGH 1 2 3 4 5 6 LOW

Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.

Employee Signature: ________________________________ Date: ____________________

Transfer/Hire Date Effective: ________________________.