Clinical Document Spec

Responsibilities

• Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team.
• Supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations, and assists with maximizing revenue.
• Recognizes gaps and facilitates modifications in clinical documentation that support the accuracy of medical conditions for inpatient encounters.
• Recognizes documentation opportunities with the assistance of computer software.
• Conducts clinical documentation improvement efforts through query processes.
• Provides oversight of EPARC, including UM and unbilled work queues.
• Communicates with individual physicians and medical team, providing guidance and clarification around principle diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in the medical record.
• Presents overall findings to key stakeholders, including leadership and peers.
• Provides education to peers and healthcare team members on documentation improvement, reimbursement opportunities, and overall performance.
• Demonstrates knowledge of trends in clinical diagnoses that result in payer denials.
• Ensures the validity of data for reporting and measuring physician and hospital outcomes through software and data analysis.
• Audits clinical documentation to confirm points of clarification have been entered in the medical record.
• Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record.
• Maintains established productivity expectations of the CDI program.
• Meets established productivity expectations of the CDI program.

Requirements

• Bachelor's degree in Nursing (BSN) and 5 years of inpatient clinical experience, knowledge of complex disease processes required OR
• Bachelor's, Master's or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 5 years inpatient clinical experience, knowledge of complex disease processes required.
• OR equivalent combination of education and experience.
• Prior experience with EPARC, eRecord, HDM, and SharePoint preferred.

Qualifications

• Registered Nurse License, current in NYS upon hire required or NP – Nurse Practitioner license, current in NYS upon hire required or PA – Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required AND
• Clinical Documentation Specialist (CDS) upon hire preferred or CDIP - Clinical Documentation Improvement Professional upon hire preferred