Clinical Documentation Specialist II - 8 Hour Days **HYBRID**

Clinical Documentation Specialist (CDS) II

The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.

Responsibilities

• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Identifies trends related to documentation issues, provider specific concerns, code specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement.

Qualifications

Education:

• High school diploma or GED required
• Bachelor's Degree in Nursing or other advanced health care field preferred
• Foreign trained MDs will be considered

License/Certifications:

• Registered Nurse, LVN, Occupational Therapist, Physical Therapist, Physician Assistant, foreign MD license or certification in Health Information Management or Medical Coding, such as RHIT, RHIA, CCDS, CDIP OR CPC, required

Experience:

• A minimum of 5 years of experience in Acute Clinical Care, Utilization Review, Coding, or Case Management required
• Working knowledge of Joint Commission standards and regulatory requirements required
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes required
• Solid computer proficiency required

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