Clinical Documentation Specialist

Essential Functions

• Provides concurrent review of the clinical documentation in the medical records.
• Concurrently queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
• Reviews medical records for opportunities for diagnosis clarification and validity as it pertains to DRG assignment.
• Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately.
• Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.
• Able to navigate within the electronic healthcare record (EHR) to obtain accurate and complete physician documentation of signs and symptoms, co-morbidities/disabilities, and other pertinent information in regard to level of care and diagnosis of the patient.
• Adheres to all coding and clinical documentation improvement guidelines by AHIMA and ACDIS.
• Develops and presents on-going documentation education for clinical staff team.

Education And Experience

• Must be a high school graduate or equivalent.
• Registered Nurse – current license (ADN or BSN) with 5 years acute care experience or comparable degree in a healthcare-related discipline with 3-5 years recent coding experience and certification of one of the following preferred: Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS).
• Strong broad-based clinical knowledge and understanding of pathology/physiology.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Able to convert weights and measures for clinical application.
• Able to analyze collected data to define and address issues.
• Excellent written and verbal communication skills and critical thinking skills.
• Computer literacy and familiarity with the operation of basic office equipment.
• Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.

Physical Requirements

• To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The individual must be able to: Stand, walk, sit, stoop, reach, lift, see, speak and hear.
• Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff.
• The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.