Clinical Data Specialist

Job Summary

The Clinical Data Specialist is responsible for ensuring the accuracy and completeness of clinical documentation to support coding and reporting compliance. The incumbent is responsible for coordinating efforts between various hospital personnel (physicians, allied health professionals, coders, etc.) to promote accurate and complete documentation of diagnoses and/or procedures in the health record.

Responsibilities

Quality of Work
Established track record of producing work that is highly accurate, demonstrates attention to detail and reflects well on the organization. Is personally committed to high quality work and encourages others to have similar standards. Assists in analyzing medical record forms/electronic order sets to assure that diagnostic terminology is consistent with clinical documentation needed to support complete and accurate reporting. Strong leadership and interpersonal skills. Excellent written and oral communication skills, as well as critical thinking skills. Schedules/participates in xxx CDI Leadership meetings by identifying educational topics and assisting with the coordination of participants' schedules. Analyzes CDI scorecard to identify improvement opportunities and educational needs. Provides feedback and focused educational programs on the results of auditing and monitoring activities to affected staff and physicians.

Understanding Roles and Responsibilities
Takes responsibility for clarifying job responsibilities, including the need to understand performance standards and other expectations. Communicates with supervisor regularly to ensure that there is no misunderstanding about how performance will be measured. Performs on-going concurrent chart reviews and assigns correct working DRG using ICD-10/PCS coding guidelines. Performs compliant, non-leading queries as validated by clinical indicators. Uses clinical/coding knowledge to assist Coding Supervisor with writing appeals to support accurate coding and reimbursement. Coordinates final reporting of diagnoses with coding staff, providing clinical recommendations as needed. Ensures the appropriate dissemination and communication of all regulation, policy and guideline changes to affected personnel.

Handling Difficult Issues
Handles sensitive or difficult issues with confidence. Remains clear-headed and focused. Remains objective in the face of strong emotions. Identifies trends and patterns and takes initiative to correct or resolve concerns by working with appropriate organizational leadership. Queries physicians for clarification and specificity of documentation in accordance with hospital policy and the AHIMA Practice Briefs "Managing an Effective Query Process", "Guidance for Clinical Documentation Improvement Programs", and "Guidelines for Achieving a Compliant Query Practice".


Encouraging Accountability
Ensures that providers and employees understand their level of accountability, including what they are responsible to deliver and are expected to undertake. Consults a physician advisor when indicated by review results, query response, or to assist in appeal process while keeping Coding Supervisor informed. Provides formal and informal clinical documentation improvement presentations, overviews, information exchange and education to all levels of staff and management and other related parties.

Relationship Building/Networking
Builds rapport and develops alliances to achieve results. Adjust communication style to meet the needs of individuals at various organizational levels. Strong leadership and interpersonal skills. Develops and coordinates education and training programs regarding appropriate documentation required for complete and accurate coding and reporting. Serves as a resource for department managers, staff, physicians, and administration to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines, and regulatory requirements.

Knowledge, Skills & Abilities

Light Work:Frequent lifting and/or carrying of objects weighing up to 10 lbs. with a maximum lifting of 25. lbs.

Five (5) years of clinical or coding experience in an acute care hospital. Working knowledge of ICD-9/ICD-10, MSDRGs, coding principles and guidelines or willingness to obtain. Knowledge of federal, state, and payor-specific regulations and policies pertaining to documentation, coding, and reimbursement or willingness to obtain. Proficient in organizational skills and planning. Proficient in computer use, including data and spreadsheet analysis, presentation programs and word processing.

Education
• Associate's Degree (Required) May substitute completion of a formal nursing program in lieu of an Associate's Degree.

Credentials
• Registered Nurse (Required)
• Registered Nurse (Required)
• Registered Health Inform Tech (Required)
• Clin Coding Spec, Cert (Required)
• Cert Doc Improvement Prac (Required)


Work Schedule: Days

Status: Full Time Regular 1.0

Location: 99 J D Anderson

Location of Job: WV:Morgantown:Mon Medical Center

Talent Acquisition Specialist: Guy S. Stewart View email address on click.appcast.io