Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) improves the accuracy and completeness of clinical documentation in medical records by performing thorough reviews and requesting clarifications from clinicians. They facilitate modifications that accurately reflect patient severity risk and resource use collaborating with clinicians and coders. The CDS ensures compliance with regulatory guidelines and supports accurate reporting of provider and hospital outcomes. They actively contribute to operational improvements and participate in education and program-related activities aligning with FMOLHS Mission values.

Job Responsibilities:

1. Documentation Review

assigned CDI reviews of inpatient medical records with concentration on review priority as designated (such as those payors with prospective payment methodology).
accurate and thorough initial and follow up CDI medical record reviews as assigned within productivity standards.
CDI review findings following processes and guidelines.
queries to physicians seeking clarity on significant diagnoses procedures complications and/or co-morbidities as indicated in order to facilitate a comprehensive clear and complete medical record.
demonstrates accurate data entry regarding CDI activity contributing to efficiency and accuracy of CDI metrics and initiatives.

2. Quality

within the compliance guidelines of Medicare and Medicaid Services.
compliance and displays ethical decision-making skills.
and complies with policies and procedures related to confidentiality of medical records.
actions consistent with FMOLHS Mission core values and service standards as daily duties are performed.
standards of performance that support patient satisfaction principles of service excellence all applicable laws regulatory agencies and accrediting bodies.
accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes.
accurate and complete record review and query outcome to comply with departmental and regulatory guidelines.

3. Collaboration/Partnership

with physicians and other clinical disciplines to clarify clinician documentation which is incomplete conflicting or non-specific.
physicians and other clinical disciplines on best documentation practices in conjunction with CDI and Coding leadership as well as physician advisors.
as a resource to clinicians for linking medical terminology and coding guidelines for improved accuracy in code assignment.
with communication between coders and physicians for retrospective querying.
with Health Information Management regarding coding analysis and education initiatives for physicians and other clinical disciplines.
with leadership and/or other clinical disciplines in matters of uncertainty.
standards of performance that support patient satisfaction and principles of service excellence.
effectively with other team members physicians and customers while always remaining tactful and friendly.
in CDI program related meetings clinician education staff development departmental activities and opportunities.

4. Research/Knowledge

knowledge of ICD-10 Official Coding Guidelines and ability to interpret documentation for appropriate working codes resulting in the correct working DRG assignment.
ability to interpret medical record documentation to determine the appropriate principal diagnosis and procedure resulting in the appropriate DRG.
ability to correlate clinical information/ detail and medical record documentation terminology for appropriate documentation clarification opportunities.
knowledge of diagnosis specificity clarification opportunities which could result in greater specificity and accuracy in code assignment.
appropriate and accurate documentation clarification requests (queries) facilitating modifications to the medical record documentation for accurate reflection of the patient s severity of illness risk of mortality and resource utilization.
knowledge relevant to role in CDI including participating in professional development and developing expertise.
as resource to CDI team members including participation in projects and/or serving as preceptor as assigned.
Clinical Documentation Specialist.

Minimum Required Exp: RN with 3 or more years of clinical nursing experience in an acute care setting or

RHIA or RHIT with 5 or more years of inpatient (acute care) ICD 10 coding experience.

Minimum Required Education: Associate or Bachelors degree in Nursing or HIM.

Required Certification/Licensure:

RN Nurse Licensure Compact (NLC) Louisiana licensed RN and/or Mississippi licensed RN
Or
RHIA with CCS Certification preferred
Or
RHIT with CCS Certification preferred