Clinical Document Specialist

Carteret Health Care · Pat Care Services PRN (as needed) Days Posted Invalid date JOB RELATIONSHIPS Reports to the Director of Research and Innovation in collaboration with the CNO/VP of Patient Care Services and CMO/VP of Medical Affairs. Works with the entire patient care team. DEFINITION OF POSITION Responsible for concurrent and retrospective auditing of medical record documentation to evaluatewhether documentation adequately reflects the care provided, resources used, patient severity ofillness, and risk of mortality. Responsibilities include facilitation of appropriate physician andAdvanced Practice Provider (APP) documentation of care to accurately capture principal andsecondary diagnoses, comorbidities, complications, and procedures. Proactively solicits clarificationfrom physicians, APPs, and clinical staff in areas where further specificity, precision, or clinicalvalidity is needed in the documentation, and consults with the attending physician or APP whenconflicting or ambiguous information appears in the medical record. Conducts compliant clinicaldocumentation queries in accordance with AHIMA and ACDIS query practice brief guidelines. Collaborates with third-party vendors, external coding auditors, and contracted CDI partners toidentify and act on documentation improvement opportunities. Participates in mortality casereviews and collaborates with quality and medical staff to analyze documentation contributing tounexpected mortality outcomes. Supports readmission reduction initiatives by reviewingdocumentation related to potentially preventable readmissions and communicating findings to careteams and leadership. Maintains documentation regarding results of audit activity and shares thosewith staff and management as necessary. This position supports the concepts and philosophies ofnursing as well as sound business practices. QUALIFICATIONS Professional Minimum of 3 - 5 years of clinical experience required with current nursing license. BSN and MSN preferred. Knowledge of current trends and issues in health care. Excellent communication and critical thinking skills. Computer experience required. Ability to work independently and meet deadlines and schedules is required. Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology. Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required. Keeps abreast of current regulations pertaining to job responsibilities. Assumes responsibility for continued professional growth and development. #J-18808-Ljbffr Carteret-Health-Care