Clinical Doc Specialist

Job Description

Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness (SOI), risk of mortality (ROM), and quality.

Completes accurate and timely record reviews to ensure the integrity of documentation compliance.

Inputs data accurately into software, resulting in precise metrics obtained through the reconciliation process.

Recognizes opportunities for documentation improvement using strong critical-thinking skills.

Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.

Transcribes documentation clarifications as appropriate to ensure documentation compliance.

Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.

Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.

Collaborates with staff to resolve discrepancies with assignments and other coding issues.

Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.

Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.

Assumes personal responsibility for professional growth, development, and continuing education to maintain a high level of proficiency.

Maintains a 95% physician response rate to all valid clarifications.

Performs other duties as assigned.

Knowledge, Skills, And Abilities

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist
• Dependable, self-motivated and pleasant
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
• Knowledge of pathophysiology, disease processes and treatments
• Strong ability to organize/triage work and manage multiple priorities at once
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures
• Coding background
• Knowledge of quality guidelines

Education

• Bachelor's of Nursing
• Master's of Nursing
• Field Of Study completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

Work Experience

• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience
• Clinical Documentation Specialist experience

Additional Information

N/A

Licenses And Certifications

• Adult Acute Care Nurse Practitioner (ACNPC)
• Registered Nurse (RN)
• Advanced Practice Registered Nurse (APRN)
• Educational Commission for Foreign Medical Graduates (ECFMG)
• Certified Clinical Documentation Specialist (CCDS)

Physical Requirements

View physical requirements here

Pay Range

$36.08 - $67.11