Clinical Documentation Specialist PRN

Facility: VIRTUAL-GA

Job Summary:

The Remote Clinical Documentation Specialist (CDS) demonstrates strong clinical knowledge and understanding of coding/DRG requirements to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The CDS works collaboratively with physicians, other healthcare professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.

Core Responsibilities and Essential Functions:

Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, mid-level providers, case management team, nursing team, other patient caregivers, and HIM coding team.
- Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation.
- Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
- Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
- Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
- Ensure queries are compliant, grammatically correct, concise and free of typographical errors.
- Provides appropriate follow up on all queries.
- Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist.
- Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated.
- Maintains required daily/weekly/monthly metrics. Meets productivity standards.
- Participates in required onsite meetings, conference calls and Skype presentations.
- Adheres to departmental Policies and Procedures.
- Participates in assuring hospital compliance with Federal and State regulatory requirements.
- Submit ideas to improve workflow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned. 80% Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintain knowledge base of current medical terminology, procedures, medications and diseases to provide accurate patient record analysis.
- Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. 5% Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes.
- Reviews data and trends to identify additional areas of opportunity.
- Provides input to core measure and other quality data initiatives regarding areas for investigation and education (PSI’s and HAC’s).
- Identify and participate in opportunities to improve documentation, EPIC, and quality of care initiatives. 15%

Required Minimum Education:
One of the following:

• Associate’s degree in nursing
• Completed degree from an accredited medical school
• Bachelor’s degree in a healthcare-related program

Required Minimum License(s) and Certification(s):

For all candidates, one of the following certifications is required within six months of hire date:

• Certified Clinical Documentation Specialist (CCDS) from ACDISx
• Clinical Documentation Improvement Practitioner (CDIP) from AHIMA

Additional License(s) and Certification(s):
For candidates with nursing background, a current/active RN license is required.

Preferred Licensure/Certification:

The following active/current coding credential from AHIMA and/or AAPC is preferred:

• Certified Coding Specialist (CCS) from AHIMA
• Certified Professional Coder (CPC) from AAPC
• Registered Health Information Administrator (RHIA) from AHIMA
• Registered Health Information Technician (RHIT) from AHIMA

Required Minimum Experience:

• Two or more years working in an acute care setting as a Clinical Documentation Specialist (CDS)
• Minimum of five years of healthcare experience required

Preferred Experience:

• Prior experience of working as a CDI/Coding auditor is preferred
• Prior experience of working in inpatient case management or utilization review is preferred

Required Minimum Skills:

• Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
• Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
• Epic and Solventum/3M 360 Encompass experience is required
• Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives · Excellent communication skills, employing tact and effectiveness
• Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members
• Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
• Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions
• Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions
• Drives optimal use of the CDI technology tool and reporting capabilities