Clinical Documentation Specialist

About This Role

This role involves evaluating medical records to ensure compliance with State and Federal regulations and providing consultation to medical records staff, physicians, and other relevant personnel. The specialist reports to the System Director, MPAS, Community CEOs, or an MPAS designee, and does not have supervisory responsibilities.

Responsibilities

• Evaluate the quality of medical record systems to ensure compliance with State and Federal regulations and medical records standards
• Review patient chart documentation for compliance with professional medical records standards and practices, as well as State and Federal regulations
• Provide consultation to physicians regarding new State and Federal regulations; advise them on the impact on medical records services and actions required for implementation and compliance
• Consult with facility administrators and their medical records staff to provide interpretations of State and Federal regulations; advise them on appropriate corrective measures for compliance
• Maintain liaison with various State, Federal, and local organizations regarding the development, definition, and administration of medical records standards and practices
• Review patients' records to ascertain if appropriate type and quality of care was given according to established criteria for the diagnosis
• Perform retrospective chart review of patients who have a change of status to assure that necessary payment status is changed
• Visit system facilities and interview administrators, nursing staff, and medical records staff to obtain information regarding policies and procedures
• Review and evaluate policies and procedures to determine that they are in writing and meet the requirements of the various regulations
• May investigate complaints regarding medical records services and prepare reports of the findings
• Perform other related duties within the scope of the job classification

Requirements

• Graduate from an accredited School of Nursing
• Current nursing licensure in the state of employment
• Possess a high degree of clinical documentation knowledge to support coding activities, medical record reviews, and physician documentation requirements
• Knowledge of clinical documentation improvement principles and healthcare documentation standards
• Ability to review, interpret, and analyze medical records for accuracy and completeness
• Possess exceptional human relations skills
• Ability to work constructively and effectively on a one-to-one basis with physicians, nursing staff, department heads, administrative personnel, health information personnel, patients, and representatives of government or third-party agencies
• Strong verbal and written communication skills