Clinical Documentation Specialist HIM

Job Summary:

Responsible for improving the overall quality, accuracy and completeness of clinical documentation within the medical record.  Conducts concurrent, retrospective, and post-bill comprehensive reviews of the clinical documentation. Facilitates updates to the clinical documentation through interactions with physicians, nursing, HIM and coding staff and other peer to peer interactions, to ensure appropriate reimbursement for the level of service rendered to all patients with a DRG based payer. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.  Educate physicians and providers on an ongoing basis through daily conversations, communication, and presentations.

Essential Functions:

• Conducts concurrent, retrospective and post-bill comprehensive reviews of the clinical documentation.

• Facilitates modifications updates to the clinical documentation to ensure appropriate reimbursement for the level of service provided to all patients with a DRG based payer.

• Demonstrates knowledge of DRG payer issues, documentation opportunities, and clinical documentation requirements.

• Improves the overall quality and completeness of clinical documentation by performing detailed concurrent, retrospective and post-bill reviews of the clinical documentation for quality improvement and financial impact on Inpatients.

• Accurately represent the severity, acuity, and risk of mortality in patients with APRDRG and query when opportunities are found.

• Accurately represent the comorbidities and major comorbidities in patients with MSDRG and query when opportunities are found.

• Ensures details are elaborated on within the physician queries to ensure they are compliant and complete by including clinical indicators, tx and documentation.

• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and organizational outcomes.

• Collaborates with Case Management, and Nursing to ensure the level of care provided to the patients is accurately reflected in the documentation and meets quality and compliance goals set forth by the facility.

• Places queries into the Electronic Medical Record and ensures the medical record reflects any changes in status, procedures/ treatments.

• Follows up on unanswered queries by contacting the provider and conferring with physician to finalize diagnoses.

• Educates all relevant internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s medical record.

• Identify gaps, inconsistencies, or omissions in documentation that impact coding, severity of illness (SOI), risk of mortality (ROM), and quality metrics.

• Act as a liaison between clinical and coding teams to ensure consistent documentation and coding practices.

• Participate in quality improvement initiatives, audits, and committee work.

• Stay current with CDI best practices, coding guidelines (ICD-10, MS-DRG, APR-DRG), and regulatory changes (CMS, OIG, etc.). – add)

• Must be computer savvy. 

• Assists with special projects.

• Provides CDI Metric Reporting and program updates to the Utilization Review Committee, when necessary.

• Advises CDI Manager and/or Director of HIM with immediate challenges that have a negative impact on the programs functions.

• Performs other duties as assigned.

Other Duties:

• Strong critical thinking skills, able to assess, evaluate and teach.  Flexible with a working knowledge of adult medicine.  Sight and hearing.

• Requires excellent observation skills, analytical thinking, problem solving, good strong verbal and written communication skills.  Professional, team player, able to communicate well with all levels of staff. Strong interpersonal skills, pleasing personality, positive demeanor.

• Performs other duties as assigned.

Minimum Education/Certifications:

Certified Coding Specialist (CCS), required. Certified Clinical Documenta