Being a Clinical Documentation Specialist involves improving the quality and completeness of clinical documentation by reviewing charts, communicating with healthcare team members, and ensuring accurate reflection of patient acuity and risk of mortality. This role supports the medical staff and healthcare team by providing daily clinical evaluations of medical records and educating on documentation opportunities.
Responsibilities
Improve the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidence-based practice, and current regulatory requirements
Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
Conduct follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient
Identify the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
Review clinical issues with coding staff to assign a working DRG, following up with physicians if appropriate
Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
Confer with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital
Gather and analyze information pertinent to documentation findings and outcomes
Educate all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies
Demonstrate knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures
Develop educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation
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
Participate in continuous performance improvement and complete all required educational programs for hospital and medical staff
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Maintain knowledge of current standards of care via literature review and participation in educational offerings
Research literature to identify new methods development and overall documentation enhancement
Complete required contact hours based on FTE status, within time frame
Maintain the integrity of data bases, track and trend response to clinical documentation and measures for performance improvement
Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate
Complete documentation on reviewed cases in the database
Complete the DRG and query indicators for each reviewed case, as appropriate
Promote patient safety by reporting of issues through established channels and participating as requested in safety initiatives
Identify patterns, trends variances and opportunities to improve documentation review and process
Demonstrate positive and effective interpersonal relations dealing with all members of the team (i.e., co-workers, physicians, leadership, etc.)
Maintain a positive attitude about assignments and team members
Promote professional/personal growth of co-workers by sharing knowledge and resources
Manage stress and personal feelings without a negative impact on the team
Communicate in a positive and productive manner
Demonstrate flexibility with changing workload/assignments
Requirements
Licensure: Registered Nurse (RN)
Graduate from an accredited school of nursing
BSN
5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience)
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem-solver with good interpersonal communication skills, verbal and written
Effective observation, analytical, and critical thinking skills
Current nursing license in the State of Illinois
Ability to work in changing environment
Ability to prioritize independently and respond to multiple simultaneous requests
Ability to work under stressful conditions and in difficult situations
Extensive knowledge and experience of ICD-10 coding classification system and DRGs
Nice to have:
Clinical documentation improvement experience
Certification in clinical documentation improvement
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