Clinical Documentation Specialist

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Job Description Summary:

Clinical Documentation provides a formalized approach to promote accurate and complete medical record documentation reflecting a patient's true severity of illness and risk of mortality. The CDS reviews inpatient medical records and identifies opportunities in provider documentation that will clarify patient severity of illness, risk of mortality, quality indicator measures and intensity of care rendered. The CDS collaborates with providers and HIM coding staff to ensure accurate clinical documentation by concurrently assigning DRGs and capturing documentation specificity to support diagnosis and clinical indicators in the medical record.

Responsibilities And Duties:

1. 50%
Reviews inpatient medical records and identifies potential opportunities in provider documentation to accurately reflect severity of illness (SOI) and risk of mortality (ROM)   Expertise includes identificaCertification in health-related field or Clinical Documentation Improvement of correct principal and secondary diagnoses through evaluation of clinical criteria present in the patient's medical record. Identifies co-morbidities and complications CC s and major co-morbidities and complications. (MCCs) in the medical record to provide additional specificity for documentation requirements. Strong critical thinking and clinical expertise are required to abstract documentation to maximize ROM, SOI, and revenue of each reviewed patient. Maintains personal communication with providers through attending multidisciplinary rounds on assigned unit.

2. 30%
Communicates with provider or designee either verbally, electronically or through written queries to request clarification or additional documentation. Responsible for escalation of unanswered queries and for communication with physician advisors to follow through outlined escalation process to complete queries. Communication requirements include conflict management and collaboration skills.

3.  10%
Exhibits expert knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions and procedures. Understand compliance standards and complies with AHIMA Standards of Ethical Coding guidelines. Understanding of hospital quality metrics and healthcare regulations are essential to provide guidance to other hospital departments regarding documentation requirements. May participate in auditing documentation or queries to facilitate interdepartmental compliance standards. Demonstrates competency of ICD10 documentation requirements. Possesses working knowledge of computer-based applications including but not limited to Word, Excel, and facility-based Electronic Health Record (EHR)

4.  5% 
Collaborates with the Health Information Management Department coding staff regarding clinical documentation to ensure accurate reflection of the patient's SOI, ROM and provider care rendered. Reviews and escalates final coding discrepancies as necessary through standardized process. Audit and communicate discrepancies in EHR codified diagnoses choices.

5.  5%
Assists with implementing plans for both formal and informal education of providers and other departments. May be assigned to collaborate with a hospital departmental committee outside CDI to provide documentation expertise. Provides general education through distribution of CDI printed materials to all providers. May assist in identification of opportunities and development of system-wide provider education including but not limited to online documentation courses, printed materials and presentations.

Minimum Qualifications:

Bachelor's Degree (Required)RN - Registered Nurse - Ohio Board of Nursing

Additional Job Description:

Field of Study: Nursing with a current RN license in the State of Ohio Critical reasoning skills in clinical decision making, problem solving