Clinical Documentation Specialist

Responsibilities

• Performs concurrent review process for all selected admissions to facilitate comprehensive complete medical record documentation to accurately reflect the diagnoses, clinical treatment, and severity of illness of the patient.
• Demonstrates in-depth clinical knowledge of complex disease processes and procedures in an inpatient setting.
• Utilize current CMS, AHA, and AHIMA coding guidelines, conventions and coding clinics to accurately determine the principal and secondary diagnoses and procedures that affect the MS-DRG assignment.
• Demonstrates an understanding of complications/co-morbidities, secondary diagnosis, impact of procedures on MS-DRG assignment, as well as severity of illness, risk of mortality, case mix, inpatient quality reporting, and denial avoidance; with ability to impart this knowledge to physicians and other members of the healthcare team.
• Develops documentation query protocol and educates essential staff on processes.
• Initiates assertive and effective communication with physician or other care provider when documentation requires clarification is unclear, using the most appropriate communication method (physician documentation request, face to face contact, phone call, etc.).
• Tracks responses and trends compliance with documentation queries.
• Identifies trends in documentation and/or potential problems and develops action plans as needed.
• Works effectively with coding staff to clarify documentation issues on the back end.
• Provides information and education as necessary to physicians not responding to documentation requests.
• Identifies patterns, trends, variances, and opportunities to improve documentation review processes.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.

Qualifications

• RN with 3 years relevant experience, OR RHIT with 3 years relevant experience, OR RHIA with 3 years relevant experience, OR CCS with 3 years relevant experience.
• Preferred Job Qualifications: 5 years of acute care hospital coding with a strong DRG background; or strong medical background with 5 years acute clinical experience preferred.