Clinical Documentation Spec

Clinical Documentation Specialist

People are our passion and purpose. Work where you are appreciated for who you are not just what you can do. At Wilson Medical Center, a 294-bed facility, we bring new and innovative programs to those who matter the most - our community. With great pride, we offer Growing Tree Child Care Center on-site daycare where children are offered a nurturing, safe environment centered around the needs of each child.

Wilson residents enjoy a community rich in educational, cultural, and social opportunities. We are home to numerous athletic and water sports, festivals, and arts and entertainment venues. From the beach to the mountains, in Wilson, you are within easy driving distance of all that North Carolina has to offer.

Health (Medical, Dental, Vision) and 401K Benefits for full-time employees

Competitive Paid Time Off / Extended Illness Bank package for full-time employees

Employee Assistance Program - mental, physical, and financial wellness assistance

Tuition Reimbursement/Assistance for qualified applicants

Opportunities for education and training through a partnership with Duke LifePoint Healthcare

Growing Tree On-Site Childcare Facility

And much more

Under the general supervision of the Director of Risk Management and Health Information Management, the Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders, and other healthcare team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for selected inpatients. The Clinical Documentation Specialist will serve as a resource to all healthcare team members on documentation guidelines and will provide guidance and support and assist with education and training related to improving clinical documentation. This position will actively educate appropriate hospital and medical staff about the changes associated with transitioning to ICD-10.

RN/LPN licensure, and/or CCDS, RHIA, RHIT, or CCS certification with prior experience in case management, utilization review, clinical documentation improvement, or coding preferred.

Must also have working knowledge of at least one of the following: Critical Care, Surgical Services or Med/Surg nursing; accreditation and regulatory compliance; hospital core measures and reporting of hospital quality data.

For RNs and LPNs: Minimum of five years experience in an acute adult in-patient clinical role with demonstrated critical thinking skills. Bachelor's degree in nursing may be substituted for two years of the required work experience

For RHIA, RHIT, or CCS certified practitioners: Minimum of two years experience with inpatient coding, process improvement in an acute care facility or equivalent experience preferred. Coding skills with experience in ICD-10, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic preferred.

Must have proven excellent communication skills in dealing with multidisciplinary clinical and operations teams, including physicians, be self-motivated, and have the ability to work within the established policies, procedures, and practices prescribed by the facility, corporation, and the immediate supervisor

Must have strong computer skills and the ability to type on a keyboard; experience with Microsoft Office products including Excel preferred

Experience in the development of reference-based continuing educational programs using Adult Learning Principles preferred

Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider

1. Will utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
2. Queries physicians on the specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy
3. Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting
4. Conducts educational sessions with physicians and other healthcare team members on documentation requirements
5. Conducts CDI on-boarding education of all new admitting physicians as part of the hospital's orientation program
6. Reviews clinical issues and identified query response concerns with physician advisors
7. Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation
8. Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic, and Official Guidelines for Coding and Reporting related to ICD-10.
9. Participates in department and facility Quality and Performance initiatives
10. Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics
11. Works in conjunction with the Directors of Quality, Medical Staff Credentialing, and medical staff leadership to ensure effective monitoring and successful completion of identified plans for improvement
12. Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance, and coding staff.
13. Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
14. Ability to establish a cooperative working relationship with diverse groups and individuals, medical staff, and other healthcare disciplines and interact with all levels of employees
15. Adheres to AHIMA "Ethical Standards for CDI Professionals".
16. Other duties as assigned.

Work is light. Moves intermittently throughout the workday. Occasional lifting of up to 30 pounds as required. The dexterity required for operating keyboards and equipment.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran