Clinical Documentation Specialist

About This Role

This role focuses on improving the quality and completeness of clinical documentation by working closely with physicians, nursing staff, other caregivers, and coding staff. The specialist ensures that documentation accurately reflects the complexity and severity of patient illnesses, analyzes clinical status to identify documentation gaps, and educates staff on compliant documentation and accurate coding.

Responsibilities

• Improve the overall quality and completeness of clinical documentation
• Facilitate modifications to clinical documentation through interaction with physicians, nursing staff, other patient caregivers, and coding staff
• Ensure documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients
• Analyze the clinical status of patients, current treatment plans, and past medical history to identify potential gaps in clinical documentation
• Educate and serve as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding
• Reconcile DRG differences between the Coding staff and Clinical Documentation Specialist
• Monitor activities to ensure all clinical documentation complies with State and Federal payer regulations

Requirements

• High School graduate or equivalent required
• If Registered Nurse, must be a graduate from NLN School of Nursing; Bachelor of Science in Nursing required
• If Registered Nurse (RN), must hold current applicable license to practice in Mississippi
• If not a Registered Nurse, must be certified by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a: Registered Health Information Administrator, Registered Health Information Technician, Certified Code Specialist, or Certified Inpatient Coder
• Complete all requirements (including continuing education) to maintain certification
• Complete de-escalation training by the end of position orientation (90 days); must have appropriate level of de-escalation training
• If a Registered Nurse, a minimum of two (2) years’ nursing experience in an acute-care facility
• If a Coder, a minimum of two (2) years’ experience in ICD-9 CM and experience utilizing ICD-10 CM and ICD-10 PCS in an inpatient setting
• Working knowledge of the AHA Coding Clinic
• Understanding of the MS-DRG payment system
• Demonstrate keen mental faculties/assessment and decision-making abilities
• Demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone
• Demonstrate strong written and verbal communication skills
• Possess emotional stability conducive to dealing with high stress levels