Clinical Documentation Specialist - RN or RHIA or RHIT
Job description
Job Title : Clinical Documentation Specialist
Job Summary : The Clinical Documentation Specialist (CDS) is responsible for improving the overall accuracy and completeness of clinical documentation within the medical record. The CDS performs record reviews on selected medical records and documents findings and opportunities. Requests clarification of clinician documentation which is incomplete, conflicting or non-specific. Facilitates modifications to medical record documentation for accurate reflection of the patient's severity of illness, risk of mortality, and resource utilization through interaction with clinicians, medical record coders, and multidisciplinary healthcare team. Serves as a resource to providers for linking medical terminology and coding guidelines for improved accuracy in code assignment. Facilitates accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes. Maintains accurate and complete record review and query outcome to comply with departmental and regulatory guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for intradepartmental and interdepartmental operational improvements. Participates in CDI program related meetings, clinician education, staff development, departmental activities and opportunities. Consistently demonstrates actions and values of the FMOLHS Mission as daily duties are performed
- Experience : Must possess one of the following experience requirements: 1. RN with 3 years clinical nursing experience in an acute care facility or 2. RHIA or RHIT with 5 years acute care coding experience with CCS certification.
- Education : Associate's or Bachelor's degree in Nursing or HIM field
- Special Skills : Knowledge of ICD-9 Codes Prefer experience in Documentation Improvement.
- Licensure : Louisiana licensed RN or RHIA with CCS or RHIT with CCS
Job Functions :
- Documentation Review
2. Quality
- Performs assigned CDI reviews of inpatient medical records with concentration on review priority as designated (such as those payors with prospective payment methodology).
- Performs accurate and thorough initial and follow up CDI medical record reviews as assigned, within productivity standards
- Documents CDI review findings, following processes and guidelines
- Submits queries to physicians, seeking clarity on significant diagnoses, procedures, complications and/or co-morbidities, as indicated, in order to facilitate a comprehensive, clear and complete medical record.
- Consistently demonstrates accurate data entry regarding CDI activity, contributing to efficiency and accuracy of CDI metrics and initiatives
3. Collaboration and Partnership- Operates within the compliance guidelines of Medicare and Medicaid Services.
- Considers compliance and displays ethical decision making skills
- Understands and complies with policies and procedures related to confidentiality of medical records
- Demonstrates actions consistent with FMOLHS Mission, core values and service standards as daily duties are performed
- Demonstrates standards of performance that support patient satisfaction, principles of service excellence, all applicable laws, regulatory agencies and accrediting bodies
- Facilitates accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes
- Maintains accurate and complete record review and query outcome to comply with departmental and regulatory guidelines
4. Research/Education- Collaborates with physicians and other clinical disciplines to clarify clinician documentation which is incomplete, conflicting or non-specific.
- Educates physicians and other clinical disciplines on best documentation practices, in conjunction with CDI and Coding leadership, as well as physician advisors
- Serves as a resource to clinicians for linking medical terminology and coding guidelines for improved accuracy in code assignment
- Assists with communication between coders and physicians for retrospective querying
- Collaborates with Health Information Management regarding coding analysis and education initiatives for physicians and other clinical disciplines
- Consults with leadership and/or other clinical disciplines in matters of uncertainty
- Demonstrates standards of performance that support patient satisfaction and principles of service excellence
- Communicates effectively with other team members, physicians and customers while always remaining tactful and friendly
- Participates in CDI program related meetings, clinician education, staff development, departmental activities and opportunities
- Demonstrates knowledge of ICD-10 Official Coding Guidelines, and ability to interpret documentation for appropriate working codes, resulting in the correct working DRG assignment
- Demonstrates ability to interpret medical record documentation to determine the appropriate principal diagnosis and procedure, resulting in the appropriate DRG
- Demonstrates ability to correlate clinical information/ detail and medical record documentation terminology for appropriate documentation clarification opportunities
- Demonstrates knowledge of diagnosis specificity clarification opportunities, which could result in greater specificity and accuracy in code assignment
- Initiates appropriate and accurate documentation clarification requests (queries), facilitating modifications to the medical record documentation for accurate reflection of the patients severity of illness, risk of mortality and resource utilization
- Maintains knowledge relevant to role in CDI, including participating in professional development and developing expertise
- Serves as resource to CDI team members, including participation in projects and/or serving as preceptor as assigned
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