GENERAL SUMMARY AND PURPOSE: 

The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the patient's severity of illness and risk of mortality by improving the quality of the physician's clinical documentation. This involves extensive record review, interaction with physicians, Health Information Management (HIM) professionals, and nursing staff. Active participation in team meetings and education of medical, nursing, and ancillary staff is a key role.  

REQUIREMENTS:  

• Registered Nurse, BSN preferred; or Certified Physician Assistant (PA-C). RHIT, RHIA, or CCDS, CDIP certification a plus. Proof of RN license is needed only in state of residence.  

• 3 to 5 years varied hospital clinical experience required. Critical care or strong medical surgical background preferred. 

• Ability to pass written clinical competency exam. 

WHAT YOU WILL DO:

•  Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. 

• Ability to quickly learn and develop the skills necessary to perform the CDS role, including ability to accurately input relevant data into 3M 360 Encompass and Cerner PowerChart (special purpose software). 

• Revenue Management 

• Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient. 

• Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications. 

• Formulates credible and compliant clarifications to improve clinical documentation of principle diagnosis, co-morbidities, evidence of indicators representing conditions present on admission (POA), and quality core measures. 

• Facilitates modifications to clinical documentation of the medical record through extensive interaction with physicians, nurses, and ancillary staff. 

• Develops and implement plans of education of physicians, nursing, and ancillary staff on documentation improvement. 

• Reviews inpatient medical records for all payer populations on admissions and throughout hospitalization. 

• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation. 

• Able to communicate effectively and appropriately with individuals at all levels of the organization. 

• Actively participate in cross functional Task Force meetings. 

• Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.  Able to effectively communicate with HIM staff and resolve discrepancies. 

• Responsible for completing all annual regulatory compliance education, as well as CDS-specific assigned education. 

• Understand and support compliant documentation strategies. 

• Knowledge of pathophysiology and disease process. 

• Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred. 

• Excellent organizational, analytical, and writing skills. 

• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills. 

• Excellent time management skills and the ability to manage multiple priorities effectively. 

• Dependable and self-directed.