Clinical Documentation Specialist (Full Time, 40, Day)

RESPONSIBILITIES

Effective Date: 10/24

I. JOB SUMMARY/RESPONSIBILITIES:

• Responsible for assisting in the overall quality and completeness of clinical documentation throughout The Queen’s Health Systems, through concurrent medical records reviews and query process.

• Responsible for the concurrent review of provider documentation to ensure the appropriate capture of Comorbid conditions and Major comorbid conditions.

• Collaborates with coding staff and quality team to ensure integrity and completeness of documentation and code assignment for the purposes of appropriate reimbursement, risk adjustment, severity of illness, risk of mortality, quality measures, and data collection.

• Serves as a training and quality resource for providers, and all members of patient care teams to ensure the integrity of medical record documentation and allow for accurate and complete medical record coding.

II. TYPICAL PHYSICAL DEMANDS:

• Sitting, walking, stooping/bending, finger dexterity, seeing, hearing, speaking.

• Frequent: standing, climbing stairs, lifting weight up to 25 pounds, carrying usual weight of 5 pound up to 20 pounds, reaching above, at and below shoulder level, repetitive arm/hand motions.

• Occasional: kneeling, walking on uneven ground, squatting.

III. TYPICAL WORKING CONDITIONS:

• Not substantially subjected to adverse environmental conditions.

IV. MINIMUM QUALIFICATIONS:

A. EDUCATION/CERTIFICATION AND LICENSURE:

• Current Hawaii State License as a Registered Nurse.

• Bachelor’s degree in Nursing.

• Current certification as a Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists (ACDIS). If not certified upon hire, certification must be obtained within thirty-six (36) months of entrance into the position.

B. EXPERIENCE:

• Two (2) years nursing experience in an acute care setting.

• Experience to demonstrate:

o Ability to learn/develop the skills necessary to implement the clinical documentation integrity activities, including knowledge of ICD-10 coding guidelines and practices, strong understanding of pathophysiology, ability to interpret regulatory guidance, using analytical problem solving skills, and engaging physicians and nursing staff in the improvement process.

o Ability to communicate effectively, both orally and in writing, with diverse professionals including physicians, nurses, case managers, and coding staff.

o Knowledge of Microsoft Office (Word, Outlook, PowerPoint and Excel).

• Prior experience in conducting chart reviews preferred.

• Knowledge and experience in ICD-10 coding guidelines, quality measures, and DRG reimbursement preferred.

• Prior experience in conducting training and education programs preferred.

Equal Opportunity Employer/Disability/Vet