Clinical Documentation Specialist

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 the inpatient population. Supports the goal of ensuring that clinical severity is captured for the level of service rendered to all patients. Capability to analyze the clinical status of the 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 DRGs as identified on the 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 Skills and Abilities.

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