The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation to obtain entitled payments, avoid fraud, and enhance quality documentation. This involves extensive record review and interaction with physicians, nursing staff, other patient care givers, and Health Information Management professionals to ensure that documentation reflects the severity of illness, level of service and quality of care rendered to all patients. Concurrently incorporates regulatory updates and guidelines into CDMP. Is a resource for and educates members of the patient care team in documentation guidelines on an ongoing basis. Communicates and interacts with all levels of professions, including but not limited to physicians, nursing, managers, ancillary staff, and office staff using various professional, appropriate and persistent techniques in a non-confrontational manner.
• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program strategies, in a timely manner.
• Recognizes opportunities for documentation improvement.
• Responsible for improving the overall quality and completeness of clinical documentation to obtain entitled payments and avoid fraud. Facilitates appropriateness of clinical documentation to ensure that documentation reflects the level of services and quality rendered to all patients. Acuity of care is accurately reflected in the medical record.
• Initiates CDMP severity worksheet for inpatients. Formulates clinically credible documentation clarifications. Conducts timely follow up on all cases and resolution to documentation clarifications.
• Interacts with physicians, nursing staff, other patient care givers, and Health Information Management professionals to ensure that documentation reflects the level of service and quality rendered to all patients.
• Demonstrates knowledge of DRG payer issues, optimization strategies, clinical documentation requirements, and referral policies and procedures.
• Improves the overall quality and completeness of clinical documentation by performing concurrent admission/continued stay reviews using clinical documentation enhancement (CDE) guidelines.
• Concurrently incorporates regulatory updates and guidelines into CDMP.
• Understands and communicates differences between Medicare Part A and Part B guidelines and how they impact DRG assignment.
• Updates the DRG Worksheet to reflect any changes in status, procedures/treatments, comorbid conditions, complications, and confers with physician to finalize diagnoses.
• Knowledge of core measures and patient safety indications.
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues.
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified have been recorded in the patient’s chart.
• Reviews clinical issues with coding staff to assign a working DRG.
• Maintains current knowledge of clinical documentation management program. Tracks and trends program compliance. Accurately enters CDMP data into system.
• Promotes performance improvement and customer service.
• Participates in Task Force meetings.
• Performs accurate input of data for trending and reporting.
Bachelor's degree in Nursing, BSN preferred.
Minimum of three years of experience as Registered Nurse in adult acute care. Inpatient Coding, Management, Utilization Review, Case Management or Quality Management experience preferred.
Current R.N. KY License
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle or feel. The employee is required to communicate effectively. Specific vision abilities required by this job include close vision for reading and computer work. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move more than 50 pounds.
The work environment described here is representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee works in an area with good lighting and climate control. The noise level in the work environment is usually moderate.