Clinical Documentation Specialist - First Reviewer (H)

About the Role

Performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge. Ensures an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement.

Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Responsibilities

• 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 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.
• Identifies issues with reporting of diagnostic testing proactively.
• 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.
• Assists in the mortality review and risk adjustment process utilizing third-party models.
• Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record.
• Imparts 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.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

Requirements

• Two years' experience in an acute care setting or relevant experience.

Qualifications

Education:

• 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).

Licenses and Certifications

State of Work Location: Illinois

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) or
• Medical Degree - Doctorate's degree or
• Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR) or
• Physician, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR) or
• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) or
• Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR) or
• APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR) or
• Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR) or
• Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR).

State of Work Location: Missouri

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) or
• Medical Degree - Doctorate's degree or
• Physician Assistant - Missouri Division of Professional Registration or
• Medical Physician/Surgeon Temporary - Missouri Division of Professional Registration or
• Medical Physician & Surgeon - Missouri Division of Professional Registration or
• Osteopathic Physicians - Missouri Division of Professional Registration or
• Registered Nurse (RN) Issued by Compact State or
• Registered Nurse (RN) - Missouri Division of Professional Registration or
• Nurse Practitioner - Missouri Division of Professional Registration.

State of Work Location: Oklahoma

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) or
• Medical Degree - Doctorate's degree or
• Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board or
• Physician Assistant - Oklahoma Medical Board or
• Medical Physician - Oklahoma Board of Medical Licensure and Supervision or
• Osteopathic Physician & Surgeon - Oklahoma State Board of Osteopathic Examiners or
• Registered Nurse (RN) Issued by Compact State or
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) or
• Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN) or
• Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP).

State of Work Location: Wisconsin

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) or
• Medical Degree - Doctorate's degree or
• Physician Assistant (PA) - Wisconsin Department of Safety and Professional Services or
• Physician - Wisconsin Department of Safety and Professional Services or
• Registered Nurse (RN) Issued by Compact State or
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services or
• Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services.

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.
• Occasional bending, stooping, kneeling, squatting, twisting, and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

Schedule

PRN / Per Diem Shift.

Benefits

• Paid Parental Leave: One week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Flexible Payment Options: Voluntary benefit offered through DailyPay for eligible hourly team members to access earned, unpaid base pay before payday (fees may apply).
• Upfront Tuition Coverage: Upfront tuition coverage through FlexPath Funded for eligible team members.