Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

Position Summary

The Clinical Documentation Specialist (CDS) 1 is responsible for extensive record review, interaction with physicians, HIM coding professionals, nursing staff, and other patient care givers to ensure accurate representation of patient severity of illness and quality of care. The CDS also participates in team meetings and develops clinical documentation guidelines and educates staff on these guidelines on an ongoing basis. The CDS may mentor, train, or lead other CDS during their orientation period and assist them with CDI policies, procedures, standard work, and systems.

Position Responsibilities

• Provides extensive and accurate reviews of medical records within specified timelines.
• Recognizes opportunities for documentation improvement to support severity of illness and quality of care and formulates clinically credible documentation clarifications/queries.
• Follows up on all cases especially those with clinical documentation clarifications/queries.
• Provides education to providers on responding to queries in the medical record and other CDI topics.
• Mets program quality and productivity guidelines and standards.
• Participates in Coding/CDI meetings and CDI H3W work group.
• Inputs review workflows and accurate data and CDI query impact into Optum and EPIC.
• Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment for compliance, reimbursement, and quality outcomes.
• Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI).
• Mets revenue cycle goals, Key Performance Indicators (KPIs), quality and productivity standards.

Training & Special Projects

• An experienced CDS 1 may assist in training and mentoring new CDS’ to become acclimated to new environment, and understanding internal policies, procedures, standard work, and workflows.

Communication

• Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory.
• Collaborates with HIM coding staff to resolve discrepancies.

Qualifications

• Education: Associates Degree or equivalent experience.
• Experience: Minimum: Registered nurse (RN) with minimum of 5 years recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent.
• PREFERRED: Registered Nurse (RN) with 8+ year’s clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent.
• 2 + years’ experience as a CDS.
• Licensure, Certification, Registration: Minimum: RN licensed in the state of CT.
• PREFERRED: Certified Clinical Documentation Specialist (CCDS) certification or Certified Clinical Documentation Professional (CDIP) certification.

Knowledge, Skills And Ability Requirements

• Ability to learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Knowledge of Pathophysiology and Disease Process.
• Working knowledge of clinical information.
• Ability to understand and communicate the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
• Must be able to function independently.
• Solid analytical capabilities.
• Strong organizational skills.
• Strong critical thinking, problem solving and deductive reasoning skills.
• Ability to handle multiple priorities and increasing responsibility.
• Strong ability to listen to and acknowledge ideas and expressions of others attentively.
• Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body language.
• Ability to collaborate with others to achieve a common goal through mutual cooperation.
• Ability to influence others for positive and productive outcomes.