Clinical Documentation Specialist, First Reviewer

Job Responsibilities and Requirements

• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI).
• Maintains appropriate productivity level.
• Conducts follow-up reviews of patients every to support and assign a working or final DRG assignment upon patient discharge, as necessary.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Attends department meetings to review documentation related issues.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy.
• Troubleshoots documentation or communication problems proactively and appropriately escalates.
• Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM.
• Affords knowledge to providers and other members of the healthcare team.
• Maintains a level of expertise by attending continuing education programs.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.

Education and Experience

• Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS).
• Two years' in an acute care setting or relevant experience.

Physical Requirements

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication.
• Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Rare climbing.

Professional License and/or Certifications

• State of Work Location: Illinois: Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• State of Work Location: Missouri: Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• State of Work Location: Oklahoma: Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• State of Work Location: Wisconsin: Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)

Work Shift

• Day Shift (United States of America)

Job Type

• Employee

Department

• 8746010033 Sys Clinical Documentation Improvement

Scheduled Weekly Hours

• 40

Benefits

• Paid Parental Leave
• Flexible Payment Options
• Upfront Tuition Coverage