Clinical Documentation Specialist

Clinical Documentation Improvement Specialist

Receive 17 Weekday Nights 26 Weekend Nights and 15 Weekend Day shift differentials Compensation Disclaimer Compensation for this role is based on a number of factors including but not limited to experience education and other business and organizational considerations. Full Time Days Position Summary: Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received support primary diagnosis secondary diagnoses and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding abstracting and reporting functions. Provide training for providers on appropriate clinical documentation as indicated. Indirectly assures case mix index DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment. Detailed responsibilities include: review in collaboration with the physician nurse patient care coordinator and certified coding specialist (CCS) identify and record principle diagnoses secondary diagnoses procedures and assign a working MS-DRG conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process document findings on the MS-DRG worksheets and identify other key quality indicators as appropriate interpret clinical information in the medical record evaluate medications vital signs surgical outcomes etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications facilitate assertive tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines coordinate and facilitate communication between Health Information Management Utilization Review/Case management Quality Management physician leadership to acquire interpret and transmit accurate diagnostic and procedure documentation identify baseline outcomes develop process improvement plans prioritize and implement process improvement action plans monitor and follow up on assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software through report analysis review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g. physicians committee intra-departmental etc.) provide information and education necessary to physicians and ancillary staff not responding to queries for appropriate follow up and consequences thereof. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coding for severity of illness and morbidity maintain confidentiality of patient records adhering to HIPAA guidelines perform other duties as assigned identify the need to clarify documentation in medical records and initiate communication with physician nurse or patient care coordinator by utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patients severity of illness and risk of mortality Qualifications: Education: Essential: Program Graduate Nonessential: Bachelor's Degree Education specialization: Essential: Nationally Accredited Nursing Graduate Nonessential: Nursing Experience: Essential: 1 year directly related experience Nonessential: Documentation improvement experience Credentials: Essential: RN in NM or as allowed by reciprocal agreement by NM Nonessential: Certified Coding Specialist Certified Doc Improvement Prac/Spec (CDIP or CDIS) Physical Conditions: Light Work: Exerting up to 20 pounds of force occasionally and/or up to 10 pounds of force frequently and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible. Working conditions: Essential: Minor Hazard - physical risks dirt dust fumes noise May work rotating shifts holidays and weekends Sign-On Bonus Available Relocation Assistance Available