What are the responsibilities and job description for the Clinical Documentation Specialist II position at Emory Healthcare?
Overview
Be inspired. Be rewarded. Belong. At Emory Healthcare.
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be.
We provide:
- Comprehensive health benefits that start day 1
- Student Loan Repayment Assistance & Reimbursement Programs
- Family-focused benefits
- Wellness incentives
- Ongoing mentorship and leadership programs
- And more!
Our Clinical Document Integrity team is leading the way in shaping the future of health care. We unite to improve lives through innovation, compassion, and an unwavering commitment to achieving unparalleled excellence in patient care.
Description
We're seeking a Clinical Documentation Specialist responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of patient acuity and to support acute care services that were delivered. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant documentation for billing of services rendered.
- Demonstrates development of analytical skills in identifying clinical documentation improvement opportunities upon medical record review. Recognizes the impact of CDI on compliance, quality patient outcomes and appropriate hospital reimbursement.
- Continues to recognize own performance limitations, but requires minimal assistance.
- Demonstrates a score of > 93% on the previous two quality assessments for the following KPIs: query compliance, PDx accuracy, and opportunity captured percentage.
- Implements quality CDI reviews independently.
- Manages time effectively. Functions in a developing leadership role. Orients staff as assigned in absence of designated preceptor.
- Demonstrates effective listening skills. Reduces barriers to facilitate communication.
- Utilizes effective conflict resolution skills. Has awareness of one's own values and how they affect interactions and relationships.
- Meets all CDS I Employee Commitments. Incumbent may work under close supervision following established routines or assigned work with limited employee latitude.
- Be essential in supporting the Hospital Value-Based Purchasing (VBP) results, by reviewing documentation to ensure accuracy in the Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Present on Admission (POA) conditions, and Mortality reviews to avoid penalties associated with lack of proper documentation. MINIMUM QUALIFICATIONS:
- Graduate of an accredited school of nursing or Foreign medical graduate from an accredited medical school.
- Current licensure as a Registered Nurse in the state of Georgia. Minimum of 3 years recent clinical experience in an acute care setting, (Critical Care, Medical/Surgical or Emergency department nursing preferred; or 2 years experience in a specialty area.) Required Certification(s): CCDS by ACDIS or CDIP by AHIMA 3 plus years of CDI experience.
- 5 years in healthcare related field with strong clinical expertise and acumen.
JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.
Additional Details
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare’s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.
