Clinical Documentation Specialist

SHIFT:

Any (United States of America)

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We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.


A Brief Overview
Under the general supervision of the Supervisor, Clinical Documentation Improvement, the Clinical Documentation Improvement Specialist (CDIS) facilitates and obtains appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity of care of the patient population. This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population. This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.

What you will do

• Essential Duties and Responsibilities:
• Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
• Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
• Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Supports and participates in the continuous assessment and improvement of the quality of services provided.
• Participates in the analysis and trending of statistical data for specific patient populations to identify opportunities for improvement
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
• Other Responsibilities:
• Adheres to established departmental policies, procedures, and objectives.
• Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
• Demonstrates a courteous and professional manner through interactions with internal and external customers.
• Integrates scientific principles and research based knowledge in decision making.
• Exemplifies a professional image in appearance, manner and presentation.
• Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
• Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
• Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient,