Clinical Documentation Specialist

The Clinical Document Specialist (CDS) is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis. The CDS promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients’ severity of illness. The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Essential Job Functions

• Reviews and re-reviews inpatient medical records for identified payer populations (primarily DRG/Case Rate payment methodology ) beginning approximately 48 after admission. Analyzes the medical record regarding the clinical status of patient, current treatment plan and past medical history and seeks clarification of incomplete, unclear, and ambiguous clinical documentation
• Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA
• Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-9 CM Official Guidelines for Coding and Reporting.
• Works closely with HIM coding staff to assure documentation of principal diagnosis and any co-existing comorbidities and complications accurately reflect the patient’s clinical status and level of services provided. Reviews attestation of all billed diagnoses and procedures and reports discrepancies to HIM coding staff
• Consistently meets established productivity targets for record review
• Develops and implements plans for both formal and informal education of physician, nursing and other clinical staff
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management
• Performs other duties as requested by senior management

Required Qualifications:

• 5 -8 years progressive work experience: Case Management or Med/Surg or Critical Care Nursing experience preferred.
• Basic computer skills in word processing and spreadsheet utilization
• Excellent interpersonal skills necessary to develop and foster effective physician communication
• Analytic skills necessary to clinically assess medical records
• Excellent prioritization and organizational skills
• Must be an actively licensed Registered Nurse
• A Bachelor's degree in Nursing

Preferred Qualifications:

• Master's degree in Nursing
• CCS coding credential

• Job Type/FTE: Full-Time 1.0 FTE
• Shift: Days
• Work Location: REMOTE
• Unit/Department: Center for Transformative Care
• CBA Code: Non-Union