Clinical Documentation Specialist

JOB SUMMARY: Uses clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation within the patient record on a concurrent basis using a multidisciplinary team process. Works collaboratively with Corporate Revenue Cycle Medical Center Inpatient Coding Quality and Analytics Case Management Medical Center physicians and midlevel providers to ensure that the clinical information within the medical record is accurate complete and compliant. This includes accurate documentation to support severity of illness expected risk of mortality hospital acquired conditions core measures and patient safety indicators. Educates members of the patient care team both formally and informally regarding documentation guidelines coding requirements and service specific requirements.

EDUCATION/EXPERIENCE: Graduation from an accredited School of Nursing with BSN and five years direct clinical nursing experience required.

LICENSURE CERTIFICATION and/or REGISTRATION: Current license to practice as a Registered Nurse (RN) in the State of North Carolina. Professional certification in Clinical Documentation (CCDS) highly recommended within two years of hire.

ESSENTIAL FUNCTIONS:

1. Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. Follows CDMP processes for conducting medical record reviews assigning a working MSDRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation appears in the medical record prior to coding and billing. Consistently meets established productivity targets for record review.

2. Reviews and resolves any clinical issues arising in the prebill stage of medical coding to insure the most accurate DRG has been assigned for billing purposes. Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation. Prompt and professional interactions are used to effectively to resolve any deficiency.

3. Collaborates with case managers nursing staff quality and analytics and other ancillary staff as needed regarding interactions with physicians on documentation to resolve physician queries prior to patient discharge. Communicates information effectively by responding to questions concerns and requests promptly. Encourages communication by promoting open dialogue.

4. Provides oneonone education to physicians midlevel providers and other key healthcare providers regarding the need for accurate specific and complete clinical documentation in the patients medical record. Support ICD10CM/PCS training for providers by reinforcing coding conventions and guidelines.

5. Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation. Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals. Analyzes clinical status of patients current treatment plan and past medical history and identifies potential gaps in physician documentation. Participates in departmental quality assurance activities.

6. Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MSDRG assignment documentation requirements ICD10CM/PCS code assignment and coding guidelines.

7. Participates in clinical documentation compliance activities including hospital acquired conditions by assuring accurate documentation resulting in the most appropriate MSDRG assignment. Conducts prebill medical record reviews assuring compliance with coding and documentation guidelines. Identifies missed opportunities related to clinical documentation and coding guidelines. Seeks additional clarification of documentation from the physician as needed in the postdischarge period in order to ensure the medical record is complete and accurate. Follows CDMP procedures for moving medical records through prebill process in a timely manner.

8. Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.

9. Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served. Knowledge of physical motor/sensory mental psychosocial safety and developmental factors in the AgeSpecific Care Guidelines is reflected in reviews of patient medical records and interactions with the multidisciplinary team.

SKILLS/QUALIFICATIONS: Strong oral written listening and interpersonal communication skills Experience in developing and presenting education programs Competent computer skills including Knowledge of Excel Microsoft Word PowerPoint and Microsoft Outlook Analytical skills Selfmotivated selfdirected and able to work independently with minimal supervision Able to work in a collaborative atmosphere Ability to accept and incorporate critical comment Well organized and detail oriented Capable of critical thinking reasoning deduction and inference while displaying the ability to draw accurate conclusions