Clinical Documentation Specialist - Level I

Duties & Responsibilities

• Facilitates improvement in the overall quality, completeness, accuracy, specificity and timeliness of physician clinical record documentation through extensive medical record review, query process, and effective communication with appropriate clinical and coding staff, and by utilizing computer programs and systems.
• Obtains appropriate physician documentation for clinical conditions or procedures through extensive on-going interaction with physicians, other patient caregivers, and medical records coding staff to ensure the clinical documentation properly captures information describing patients’ acuity, severity of illness, and risk of mortality.
• Reflects the level of service delivered to patients is appropriate, complete, and accurate and supports appropriate reimbursement for the level of service rendered to all patients.
• Completes concurrent and retrospective reviews of patient records for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, postadmission complications and procedures for accurate Diagnosis-Related Group (DRG) assignment and Case Mix Index (CMI), risk of mortality, and severity of illness.
• Queries physicians for incomplete, inconsistent, unclear or conflicting health record documentation to clarify and resolve conflicting information in patient’s medical record prior to patient’s discharge; maintains a record of review and query activities and other appropriate records.
• Provides feedback and completes follow-up review of patient medical record, to ensure points of clarification have been addressed and recorded in the patient’s chart, and to assign a working/updated or final DRG upon patient discharge and before final coding and quality reporting submissions, as necessary.
• Identifies and reports areas of weakness that may impact financial opportunities, and works with Finance or other appropriate staff in resolution of problems.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Aids in the preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
• Assists with the orientation and training of new staff members, and provides continual guidance and mentoring, as required.
• Educates providers on proper clinical documentation and coding guidelines and practices, and compliance and reimbursement issues on an ongoing basis.
• Advises on the impact of provider documentation on accurate reporting of a patient’s clinical information and reimbursement.
• Attends and/or participates in staff, departmental and interdisciplinary meetings, LEAN efficiency/process improvement events, training and quality assurance/performance improvement (QA/PI) activities.

Requirements

• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED); and Bachelor of Science in Nursing degree from an accredited college or university; and four (4) years of acute care experience;
• Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issued by the NYSED; and two (2) years of experience, as described in “1” above;
• Valid New York State license and current registration to practice as a Physician Assistant (PA) issued by the NYSED; and two (2) years of experience, as described in “1” above;
• Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience;
• Successful completion of education that leads to a medical degree; and two (2) years of experience, as described in “4” above.

Department Preferences

• Knowledge of CDIS Guidelines.
• Proficiency in EPIC 3M360.
• Familiarity with AHIMA Coding Guidelines.