CLINICAL DOCUMENTATION SPECIALIST

  • Campbell County Health
  • Gillette, WY
  • Jun 23, 2021
Full Time Assistant/Support

Job Description

Working in conjunction with the Director of Health Information Management (HIM), the CDS facilitates accurate documentation for severity of illness and quality in the health record with minimal direction. This involves extensive record review, financial knowledge, clinical knowledge,interaction with physicians, health information management professionals, and nursing staff. Active coordination of and participation in team meetings and education of staff in the CDI process is a key role. Improves documentation to reflect quality and outcome scores. CDS will provide active concurrent/retrospective review, provide feedback and educate providers to improve the documentation to accurately reflect the condition of the patient. PRIMARY JOB DUTIES Audits medical record for completeness and accuracy for severity of illness (SOI) and quality using thecurrent CDI software package. Audits medical records on admission and throughout hospitalization Analyze clinical information to identify areas within the chart for potential gaps in provider documentation Formulates provider queries concurrently and retrospectively with approved templates including when applicable clinical indicators and medical evidence to improve clinical documentation of principle diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI) to be included as a part of the legal record. Facilitates modification to clinical documentation through extensive interaction with physicians, nurses and ancillary staff as appropriate. Works collaboratively with coding specialists to assure documentation of discharge diagnosis and co-morbidities are a complete reflection of the patient’s clinical status and care Works collaboratively with coding specialists to improve their clinical knowledge. Works with utilization staff to ensure patient is in correct status. Works with utilization review and HIM in preparing responses to third-party audits as needed. Development, coordinate and grow program to include other areas as directed by management Accurate and timely record review Recognizes opportunities for documentation improvement Supports accurate diagnostic and procedural coding, and MS-DRG assignment, leading to appropriate reimbursement. Requests documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety Effective and appropriate communication with physicians, nurses and coding professionals. Timely follow up on all cases and resolution of those with clinical documentation clarifications Manage multiple priorities Communicates and collaborates frequently with HIM staff and resolves discrepancies Knowledge of Core Measure and Patient Safety Indicators (upon completion of training) Prepares data for and attends meetings with HIM Director to discuss goals and objectives, as well as tactics for improvement/progress Provides service excellence to all customers with utilization of AIDET. Demonstrates efficient time management and prioritization skills. Maintains professional standards related to clinical practice, staffing and continuing education. Practices fiscal responsibility and accountability. Maintains a clean and safe environment. Adheres to CCH policies and procedures. Complies with the hospital’s Corporate Compliance Program including, but not limited to, the Code of Conduct, laws and regulations, and hospital policies and procedures. Must be free from governmental sanctions involving health care and/or financial practices. Performs other duties as assigned. JOB SPECIFICATIONS Education: Minimum associate degree in healthcare field (e.g. nursing, health information management) or equivalent combination of education/experience combined. Graduate of an accredited school of nursing. Bachelor’s degree in healthcare field; (e.g. nursing, health information management) preferred Licensure: Active Wyoming license. (with on-time renewal) Previous coding-ICD-9, ICD-10 experience preferred Certifications required: See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy. Experience: Minimum of 2 years medical/surgical or ICU nursing required, 5 years preferred Essential Technical/Motor Skills: Clear and direct communication skills to communicate with physicians, nursing staff, coders, executives and contractors. Interpersonal Skills: Ability to develop positive interaction with physicians, coders, contractors, executives, and staff in order to effectively reach documentation goals. Essential Physical Requirements: Ability to lift and/or maneuver objects weighing 40 pounds or less in the assessment and implementation of patient care, should the need arise. This position typically requires many hours of sitting. Essential Mental Abilities: Must be able to function in the capacity of a registered nurse if needed. Must be able to work autonomously once trained, and remained focused and steadfast with the goal in mind. Position requires critical thinking, problem solving and management of multiple priorities. Must be skilled with crucial or difficult conversations due to the nature of the role. Essential Sensory Requirements: Corrected vision, hearing to normal range. Exposure to Hazards: OSHA CATEGORY I. TASK THAT INVOLVES EXPOSURE TO BLOOD, BODY FLUIDS, OR TISSUES. All procedures or other job-related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues, or potential for spills or splashes of them, are Category I Tasks. Use of appropriate protective measures is required for every employee engaged in Category I Tasks. Employees working in healthcare facilities have the potential to be exposed to hazardous materials including: Hazardous Chemicals/Drugs, Waste Anesthetic Gases, Radiation, Latex, Biological Hazards, Respiratory Hazards and Ergonomic Hazards. See Hazardous Materials in the Workplace Policy.

Employment Type

Full Time