Clinical Documentation Specialist

Job Responsibility

• Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record.
• Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded.
• Works with physicians on assigned patient care units to clarify clinical documentation in the patient’s medical record through a concurrent review process throughout the patient’s inpatient stay.
• Requests clarification of clinical documentation from the physician(s) on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge.
• Ensures the level of service rendered to patients, and the patient’s severity of illness is accurately documented and recorded.
• Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record.
• Interacts with physicians as needed to discuss and advise on clinical documentation requirements and provides timely and accurate responses to clinical documentation and coding questions.
• Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Reconciles reviewed cases to update any changes in status, procedures/treatments, and confer with providers to finalize diagnoses.
• Educates medical staff on clinical documentation opportunities that impacts the accuracy of the medical record.
• Inputs outcome data in the CDI software to be able to track response to queries.
• Responsible for file maintenance including entry into database for tracking and trending audit results.
• Communicate findings of potential or missed diagnoses and the revenue impact that were discovered during the chart audit.
• Regularly exercises independent judgment on matters of significance within defined procedures to determine appropriate actions/approaches.

Job Qualification

• Graduate from an accredited School of Nursing required.
• Must obtain a Bachelor of Science in Nursing degree within 5 years of employment date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. (CCEDS and CCS)
• 1-3 years of relevant experience, required.