Clinical Document Specialist

JOB SUMMARY:

• Responsible for improving the overall quality and completeness of the Clinical Documentation integrity of the electronic medical record from which the assignment of diagnosis/procedure codes to ensure the DRG’s reflecting severity of illness and intensity of services rendered are assigned.
• Facilitates modifications to the Clinical Documentation integrity through extensive review of the electronic medical records and interaction with Physicians and HIM Coding Staff to ensure that appropriate reimbursement is received for the level of service rendered.
• Demonstrates proficiency with Clinical Documentation integrity concepts, practices and processes. Will act as a liaison to successfully integrate Clinical Documentation Integrity and Coding and Quality (Patient Safety Indicators (PSI’s) / Hierarchical Condition Category (HCC’s).  
• Documentation should promote accurate, complete and consistent Clinical Documentation in accordance with regulatory and documentation standards and requirements as well as all applicable official coding conventions, rules and guidelines. 
• This position will be responsible for the concurrent identification, review and validation of potential in hospital Patient Safety Indicators (PSI’s), complications, and adverse events following surgeries and procedures. 
• The position facilitates clarification of Clinical Documentation integrity through electronic medical record review, interaction with physicians, nursing staff and other members of the patient care team utilizing the measure inclusion and exclusion technical specifications.
• The position will work with and support the interdepartmental relationships between Quality, Case Management/Utilization, HIM, and Coding toward processes and outcomes that incorporate the multitude of uses in today's fee-for-value healthcare delivery model

REQUIREMENTS:

• Minimum 2 years, 5 years preferred, acute hospital experience as a clinical nurse in Medical/Surgical Nursing / Critical Care / or Emergency Department preferred
• Licensure/Certification/Registration: at least one of the following required: RN/ BSN; CCDS certification desired.
• CCDS Certification within 2 years of hire