Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) improves the accuracy and completeness of clinical documentation in medical records by performing thorough reviews and requesting clarifications from clinicians. They facilitate modifications that accurately reflect patient severity, risk, and resource use, collaborating with clinicians and coders. The CDS ensures compliance with regulatory guidelines and supports accurate reporting of provider and hospital outcomes. They actively contribute to operational improvements and participate in education and program-related activities, aligning with FMOLHS Mission values. Responsibilities Documentation Review Perform assigned CDI reviews of inpatient medical records with concentration on review priority as designated (such as those payors with prospective payment methodology). Perform accurate and thorough initial and follow up CDI medical record reviews as assigned, within productivity standards. Document CDI review findings, following processes and guidelines. Submit queries to physicians, seeking clarity on significant diagnoses, procedures, complications and/or co‑morbidities, as indicated, in order to facilitate a comprehensive, clear and complete medical record. Consistently demonstrates accurate data entry regarding CDI activity, contributing to efficiency and accuracy of CDI metrics and initiatives. Quality Operate within the compliance guidelines of Medicare and Medicaid Services. Consider compliance and display ethical decision making skills. Understand and comply with policies and procedures related to confidentiality of medical records. Demonstrate actions consistent with FMOLHS Mission, core values and service standards as daily duties are performed. Demonstrate standards of performance that support patient satisfaction, principles of service excellence, all applicable laws, regulatory agencies and accrediting bodies. Facilitate accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes. Maintain accurate and complete record review and query outcome to comply with departmental and regulatory guidelines. Collaboration and Education Collaborate with physicians and other clinical disciplines to clarify clinician documentation, which is incomplete, conflicting, or non‑specific. Educate physicians and other clinical disciplines on best documentation practices, in conjunction with CDI and Coding leadership, as well as physician advisors. Serve as a resource to clinicians for linking medical terminology and coding guidelines for improved accuracy in code assignment. Assist with communication between coders and physicians for retrospective querying. Collaborate with Health Information Management regarding coding analysis and education initiatives for physicians and other clinical disciplines. Consult with leadership and/or other clinical disciplines in matters of uncertainty. Demonstrate standards of performance that support patient satisfaction and principles of service excellence. Communicate effectively with other team members, physicians and customers while always remaining tactful and friendly. Participate in CDI program related meetings, clinician education, staff development, departmental activities, and opportunities. Research/Knowledge Demonstrate knowledge of ICD‑10 Official Coding Guidelines, and ability to interpret documentation for appropriate working codes, resulting in the correct working DRG assignment. Demonstrate ability to interpret medical record documentation to determine the appropriate principal diagnosis and procedure, resulting in the appropriate DRG. Demonstrate ability to correlate clinical information/details and medical record documentation terminology for appropriate documentation clarification opportunities. Demonstrate knowledge of diagnosis specificity clarification opportunities, which could result in greater specificity and accuracy in code assignment. Initiate appropriate and accurate documentation clarification requests (queries), facilitating modifications to the medical record documentation for accurate reflection of the patient's severity of illness, risk of mortality and resource utilization. Maintain knowledge relevant to role in CDI, including participating in professional development and developing expertise. Serve as resource to CDI team members, including participation in projects. Qualifications Minimum Required Experience: RN with 3 or more years of clinical nursing experience in an acute care setting OR RHIA or RHIT with 5 or more years of inpatient (acute care) ICD‑10 coding experience. Minimum Required Education: Graduated from an accredited school of nursing or Associate in Nursing or HIM. Required Certification/Licensure: RN Nurse Licensure Compact (NLC), Louisiana licensed RN and/or Mississippi licensed RN. RHIA with CCS Certification preferred. RHIT with CCS Certification preferred. #J-18808-Ljbffr Franciscan Missionaries of Our Lady Health System Inc