Clinical Documentation Specialist

About This Role

The Clinical Documentation Specialist is responsible for reviewing patient clinical documentation to ensure accurate representation of their condition through complete and precise reporting of diagnoses and procedures. This role involves working closely with physicians and coding staff to clarify documentation issues and provide education.

Responsibilities

• Perform concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects all disease processes being treated or affecting care while the patient is hospitalized by analyzing documentation for incompleteness, identifying ambiguous, conflicting or clinically incongruent documentation and ensuring the documentation supports treatment being provided
• Assist with the development of physician queries to ensure compliance with the query process in an effort to obtain the correct clinical diagnoses and capture of severity of illness by incorporating clinical indications and clinical knowledge in the development of the query
• Initiate assertive professional communication with physicians when documentation is unclear, incomplete or lacks the necessary completeness to assign ICD-10 codes by completing query form or face-to-face communication with the physician
• Track responses to questions on documentation by trending compliance with documentation queries in an effort to identify opportunities for physician feedback and education
• Work with coding staff to clarify documentation issues by meeting with the coding staff on a regular basis to ensure understanding of documentation requirements
• Maintain collaborative relationship with staff nurses, care coordinators, utilization review staff, inpatient coding staff and all hospital and health System personnel
• Provide education/training to physicians, physician office staff, nurses and coders in a variety of settings: one on one; group presentations and quick sessions during rounds
• Work in partnership with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index

Requirements

• Graduate of an accredited school of nursing
• Successful completion of annual mandatory education requirements

Nice to have:

• Bachelor of Science in Nursing (BSN)

Important Details

• Schedule: Monday - Friday, daytime business hours

About the Company

At Nebraska Methodist Health System, the focus is on providing exceptional care to the communities served and people employed. They offer a great work environment where all employees are valued and are part of a team that makes a real difference in the communities they live and work in.