Clinical Documentation Specialist RN

About the Role

Come lead with us at Corporate. The Clinical Documentation Specialist RN is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRGs, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. The role facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure appropriate reimbursement for the level of service rendered. Additional duties include supporting the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, and educating all members of the patient care team on an ongoing basis.

Responsibilities

• Improves the overall quality, completeness, and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines.
• Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
• Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary.
• Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to the scope of the department.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements, and referral policies and procedures.
• Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information.
• Helps identify appropriate ICD-10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
• Promotes clarification to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered to all patients.
• Identifies diagnoses and procedures performed, as well as comorbidities and complications.
• Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physicians to finalize diagnosis as necessary.
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

Requirements

• Five years of recent clinical experience caring for adults in an acute care hospital setting.
• Coding and utilization review experience preferred.

Qualifications

Graduate of an education program approved by the credentialing body for the required credential(s).

Skills

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations.
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
• Ability to effectively communicate with patients, physicians, family members, and co-workers in a manner consistent with a customer service focus and application of positive language principles.
• Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures.
• Demonstrates accountability and professional development.
• Excellent observation skills, analytical thinking, problem-solving, plus good verbal and written communication.
• Regular significant contacts with other personnel throughout the institution (including but not limited to physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence.
• Requires assertiveness while being even-tempered, with a pleasing personality and the ability to communicate easily with others.

Licenses and Certifications

• Required: RN - Registered Nurse - Texas State Licensure (Texas Board of Nursing). PSV Compact Licensure – Must obtain permanent Texas license within 60 days if establishing Texas residency.
• Preferred: CCDS - Clinical Documentation Specialist (ACDIS), CDIP - Certified Documentation Integrity Practitioner (AHIMA), or CCS - Certified Coding Specialist (AHIMA).

Work Attire

Business professional attire is required.