Clinical Documentation Specialist

About This Role

This hybrid position, both onsite and remote, focuses on improving the overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality. The specialist interacts extensively with physicians, case management, nursing staff, other patient caregivers, and coding staff, ensuring the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

Responsibilities

• Initiate and perform concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected
• Meet or exceed defined performance standards for chart reviews and queries
• Improve coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay, including capturing complications/co-morbidities
• Serve as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment
• Follow guidelines for coding and documentation to ensure physician and hospital compliance
• Remain current with coding information to ensure accuracy of codes assigned based on documentation
• Participate in educational programs and in-services to maintain and exceed excellence in coding skills
• Perform ongoing CDI Final Review/DRG Reconciliation and report DRG mismatch disagreements for secondary review as defined
• Perform ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities
• Support the Coding Department through communicating with physicians regarding open queries; act as liaison between coding and physicians
• Identify, assist, and participate in inter/intra-departmental special projects involving the accuracy of physician documentation
• Participate in precepting and mentoring of new team members
• Collaborate with the Physician Advisor in identifying patterns of physician documentation issues, utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings
• Maintain established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards
• Maintain confidentiality and security levels to protect medical/legal patient care documentation

Requirements

• Knowledge of care delivery documentation systems and related medical record documents
• Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment
• Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff