Senior Clinical Documentation Specialist

Clinical Documentation Improvement Specialist

This position is responsible for assisting in the daily operation of the Clinical Documentation Improvement (CDI) team and fulfills all assignments relative to the clinical documentation improvement specialist. The clinician will help direct the daily responsibilities of the clinical documentation improvement specialists and fulfill responsibilities of a clinical documentation improvement specialist including reviewing medical records and identify potential DRG assignment based on clinical indicators to improve the quality of documentation ensuring compliance established by State and Federal Regulations.

This position will be responsible for assisting in the daily operation of the Clinical Documentation Improvement by directing daily assignments, answering questions from the CDI team, providing direction when problems are encountered, orienting new CDI specialists, and assisting the CDI director in providing CDI education and maintaining the CDI software (CDMP) access and use by the users.

Incumbent reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The clinician is responsible for translating diagnostic phrases utilized by healthcare providers into coded form. The translation process required interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then utilized for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large. The clinician is charged with assigning the appropriate DRG after concurrent review of the medical record.

The clinician must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for DRG. The clinician must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. The clinician works as a part of a coding team to achieve and ensure that there is no coding disagreement with the DRG.

This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in treatment modes and new procedures, and to perform coding when physician documentation is vague or missing. This position does not provide patient care.

Minimum Qualifications:

Requirements - Required and/or Preferred

Name: Description

Education: Ability to read, write, speak, and understand English sufficiently to perform job duties safely and effectively. A bachelor's degree in a related field is required or equivalent experience in lieu of degree.

Experience: Minimum 5 years acute hospital experience working as a Registered Nurse required. Knowledge of ICD system and leadership experience preferred.

License(s): Ability to obtain and maintain a State of Nevada Registered Nurse license or licensure from state in which they have residency.

Certification(s): Certified Clinical Documentation Specialist (CCDS) by ACDIS or Certified Documentation Improvement Professional (CDIP) by AHIMA is required at time of hire.

Computer / Typing: Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, Teams, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.

Disclaimer: The foregoing description is not intended to be, and should not be construed as, an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.