Clinical Documentation Specialist

 Works Works under the supervision of the Director, Health Information Services.  Responsible for ensuring the overall quality and completeness of clinical documentation. Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. This position is responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. The Clinical Documentation Specialist (CDS) is required to generate queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation. The CDS provides ongoing physician education about coding and reimbursement and collaborates with various departments to include Case Management, Quality and HIM/Coding. In addition, the CDS performs chart audits as needed and assists in preparation transition to ICD-10.  Supports timely, accurate and complete documentation and analysis of clinical information used for measuring and reporting physician and Hospital outcomes.  Educates all members of the patient care team on an ongoing basis.  Actively contributes to the morale and teamwork of the staff and facility always presenting a positive attitude and patient minded vision with patient satisfaction as the continuing goal.

If a HIM Professional:

RHIT, RHIA and 3 - 5 years of experience with coding, abstracting and DRGs, APGs and APCs knowledge. 

Working knowledge of ICD-9-CM and ICD-10-CM coding principles and guidelines, SOI-ROM, HAC's, PSI's and Value Based Purchasing    Be well versed in both outpatient and inpatient documentation requirements as well as possess clinical knowledge for proper code assignment and query request.  Thorough knowledge of medical terminology, pathophysiology, pharmacology and anatomy and physiology.  Working knowledge of federal, state and payer-specific regulations and policies pertaining to documentation, coding and reimbursement or willingness to obtain this knowledge  Strong project and process management, leadership and interpersonal skills.  Excellent written and oral communication skills.  Critical thinking skills.

If an RN:

Current valid New York State Registered Nurse License. 3-5 years' experience in utilization management, Health Information Management, acute care clinical nursing, Quality Improvement, or a related field preferred.