About This Role
This role involves using advanced clinical and coding expertise to ensure the integrity of clinical documentation. The Clinical Documentation Specialist reviews, educates, and consults to facilitate the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.
Responsibilities
- Utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation
- Facilitate the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review
- Interact extensively with physicians and other members of the healthcare team to achieve appropriate clinical documentation
- Support code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered to all patients
- Participate in the development and delivery of education for providers and members of the healthcare team
- Demonstrate understanding of appropriate clinical documentation to ensure accurate reflection of severity of illness, risk of mortality, quality indicators, and level of services provided
- Assist in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication, and quality outcomes
- Serve as a resource for appropriate clinical documentation
- Communicate with and educate physicians and all other members of the healthcare team regarding clinical documentation
- Monitor provider engagement and identify learning opportunities for healthcare providers
- Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation
- Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures
- Interact with physicians, nurses, and ancillary staff regarding compliant documentation requirements, clarification/query requests, and educational opportunities
- Code all relevant, appropriate, and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR)
- Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
- Resolve all discrepancies in a courteous manner
- Demonstrate expertise in problem-solving skills based on theoretical knowledge, clinical experience, and sound judgement
- Serve as a professional role model by demonstrating desirable practice behaviors
- Leverage the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness
- Perform other duties as assigned by leadership
