Clinical Documentation Specialist II

At Abrazo Community Health Network, we understand that our greatest asset is our dedicated team of professionals. We provide a supportive and collaborative environment where you can work with advanced technology and make a positive impact on patients' lives.

Benefits

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance Program
• Employee discount program
• Voluntary benefits including pet insurance, legal insurance, accident and critical illness insurance, long-term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status.

About the role

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality. This role ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

Responsibilities

• Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions, diagnoses, and procedures where inadequate or conflicting documentation is suspected.
• Meets or exceeds defined performance standards for chart reviews and queries.
• Improves coding specificity by educating physicians, clinicians, and other involved parties on the necessity of complete and clear documentation throughout a patient’s stay, including capturing complications and comorbidities.
• Serves as a resource for physicians to link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
• Follows guidelines for coding and documentation to ensure physician and hospital compliance.
• Remains current with coding information to ensure accuracy of codes assigned based on documentation.
• Participates in educational programs and in-services to maintain and exceed excellence in coding skills.
• Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review.
• Performs ongoing query reconciliation with regular monitoring of query outcomes for performance opportunities.
• Supports the Coding Department by communicating with physicians regarding open queries; acts as liaison between coding and physicians.
• Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.
• Collaborates with the Physician Advisor to identify patterns of physician documentation issues, utilization/follow-up of queries, and education of physicians at the bedside or monthly meetings.
• Maintains established hospital and departmental policies and procedures, objectives, performance improvement programs, safety, environmental, and infection control standards.
• Maintains confidentiality and security levels to protect medical/legal patient care documentation.
• Participates in orientation, precepting, and mentoring of new team members.
• Performs other related job tasks or responsibilities as assigned.

Requirements

• Knowledge of care delivery documentation systems and related medical record documents.
• Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
• Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physicians, case management, nursing, coding, and hospital staff.
• Computer skills and familiarity with basic office equipment.
• Ability to work independently in a time-oriented environment.
• Self-directed, motivated, and possess a positive attitude.

Qualifications

Education: Graduate of an accredited school of nursing, AHIMA-accredited school, United States or international school of medicine.

Experience: 2-5 years of Clinical Documentation Specialist (CDS) experience.

Licensure/Certifications: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP.

Pay

$35.85 - $55.55 hourly. Individual wages are determined based on qualifications and experience.