Clinical Documentation Specialist II- Full Time Days
Cape Fear Valley Health · Fayetteville, NC · 1 wk ago
HealthcareFull-time
Major Job Functions
- Identify the most appropriate principle diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulations
- Facilitate modifications to clinical documentation that support the clinical severity of services, clinical validity rendered to all patients with a DRG base Payor (i.e. Medicare, Medicaid, Commercial, etc.)
- Review coding & clinical issues with coding staff to assign the most appropriate working & final DRG
- Complete follow-up/continued stay & potential retrospective reviews of clinical documentation and updates worksheets/findings at least every 24-48 hours or as indicated
- Conduct follow-up/continued stay reviews of clinical documentation to ensure points of clarification documented in the patient’s chart are met
- Confer with physicians face-to-face, via Epic Secure chat, phone and/or via queries to clarify information in medical record, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity of the patient
- Assist with education for all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
- Review charts with Senior Lead CDIS and/or CDIS Director if unable to reach an agreement with Clinical Coding Specialists
- Aids other team members to ensure completion of all work assignments
Minimum Qualifications
- Education And Formal Training: Associate’s degree in Nursing required, Bachelor's degree in Nursing preferred
- Medical/Osteopathic Doctorate (MD/OD) or an international qualified physician (IMD/MBBS) preferred
- Nurse candidates must have current Registered Nurse licensure in North Carolina or compact/multi-state license required
- Work Experience: Nursing candidates must have 5 years of clinical experience in inpatient hospital setting with 1 year of critical care experience (ED, ICU, etc) required
- Medical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required
- 2 years of ICD-10 CDIS experience required
Required Licenses And Certifications
- RN - Board Of Nursing