Clinical Documentation Specialist (Remote)

About This Role

This remote position is responsible for the concurrent review of inpatient medical records to find opportunities for improving the quality of physician documentation. The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team, both face-to-face and electronically. The goal of this position is to achieve a complete medical record to support complete, accurate, and timely coding.

Responsibilities

• Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients
• Utilize the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes
• Provide or coordinate education to all internal customers related to compliance, coding, and clinical documentation issues
• Act as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• Evaluate documentation by the medical staff and healthcare team daily in accordance with the hospital’s designated clinical documentation system
• Gather and analyze information pertinent to documentation findings and outcomes
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization
• Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends
• Identify patterns, trends, variances, and opportunities to improve documentation review and process
• Research literature and stay abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement
• Assist in the development and reporting of performance measures to the medical staff and other departments
• Prepare physician-specific data information
• Conference with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation
• Coach physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness
• Document conference and results
• Attend various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities
• Comply with HIPAA and Code of Conduct policies
• Assist with special projects as needed
• Demonstrate competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation