Clinical Documentation Specialist

Employee Type: Regular

About the Role

The Clinical Documentation Specialist is responsible for day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the Clinical Documentation Program. Ensures overall quality and completeness of clinical documentation for Medicare, Medicaid or other payers for inpatient population. Supports the goal of ensuring that clinical severity is captured for the level of service rendered to all patients.

Capability to analyze clinical status of patient, current treatment plan, and past medical history to identify potential gaps in Provider documentation. Able to work closely with Coding staff to assure documentation of discharge diagnoses and co-existing comorbidities are a complete and accurate reflection of the patient's clinical status and care. Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Responsibilities

• Participate in targeted second level reviews of high or low outlier medical/surgical DRG’s as identified on quarterly PEPPER report
• Assist in education to Medical Staff including Residents, designated Committees and hospital staff on interpretation and communication techniques for obtaining appropriate medical record documentation
• Take an individual, active role in achieving the departmental SMART goals that support the pillars of the organizational strategic objectives
• Utilize monitoring tools to track the progress of the Clinical Documentation Program
• Participate in the implementation of new service lines for the organization to identify documentation needs of diagnoses and procedures being implemented

Qualifications

Education

• Bachelor's Degree: Required
• Bachelor's Degree in nursing or clinical Degree in related field: Preferred

Experience

• Two (2) years’ experience in the Clinical field, Coding, Care Management or any combination of education, training and/or experience which demonstrates competence as described in Special Skills and Position Summary

Skills and Abilities

• Strong Clinical background
• Exceptional problem-solving, time management and organizational skills
• Ability to work independently and communicate effectively and efficiently with Medical Staff and Healthcare Team
• Strong familiarity with medical practices, especially disease management and health and wellness programs
• Works with the Medical Staff and Documentation Team members to provide physician and staff education related to clinical documentation
• Extensive knowledge of medical terminology and regulatory agency requirements
• Exceptional written and verbal communication skills in order to establish and maintain successful working relationships with all levels of staff
• Possess tact, initiative and confidence to meet the essential functions of the position

Licenses and Certifications

• Registered Nurse - South Carolina Department of Labor, Licensing and Regulation: Required
• Registered Health Information Administrator - American Health Information Management Association: Required
• Certified Coding Specialist - American Health Information Management Association: Required

Physical Demand

Light Physical Demand

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a contract for employment nor a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform tasks other than those specifically presented in this description.