Role Description

Performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Qualifications

• Must have prior experience as a Clinical Documentation Specialist
• 1 year of experience as a Clinical Documentation Specialist
• Additional two years in an acute care setting or relevant experience
• Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)
• CCDS certification preferred
• Proficiency with MS Office Tool - especially Excel
• Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews

Requirements

• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI)
• Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary
• Queries physicians regarding missing, unclear, or conflicting health record documentation
• Identifies issues with reporting of diagnostic testing proactively
• Enhances expertise in query development, presentation, and standards
• Educates physicians and key healthcare providers regarding clinical documentation improvement
• Attends department meetings to review documentation related issues
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics
• Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy
• Troubleshoots documentation or communication problems proactively
• Reviews and clarifies clinical issues in the health record with coding professionals
• Assists in the mortality review and risk adjustment process utilizing third-party models
• Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record
• Imparts knowledge to providers and other members of the healthcare team
• Maintains a level of expertise by attending continuing education programs
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice
• Works in a constant state of alertness and safe manner
• Performs other duties as assigned

Benefits

• Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE)
• Flexible Payment Options: instant access to earned, unpaid base pay through DailyPay (fees may apply)
• Upfront Tuition Coverage: provides upfront tuition coverage through FlexPath Funded for eligible team members