Clinical Documentation Specialist

Under the leadership of the Clinical Documentation Improvement (CDI) Supervisor, the Clinical Documentation Specialist focuses on the accuracy, completeness and consistency of inpatient Clinical Documentation to support coding and reporting of high-quality healthcare data.  Performs concurrent Clinical Documentation chart reviews to ensure the medical record appropriately describes the patient’s severity of illness and risk of mortality.

Primary Duties and Responsibilities:

• Develops and delivers education for providers and other members of the healthcare team.
• Performs extensive medical record reviews and queries.
• Assists with other medical record and documentation assignments as needed.
• Complies with HIPAA regulations.
• Demonstrates a customer-service, high satisfaction approach to work with providers and patients.
• Maintains professional rapport with physicians, nurse practitioners, and physician assistants.
• Improves quality, completeness, and accuracy of Clinical Documentation.
• Maintains appropriate records, reconciling information with external and internal sources, if necessary.
• Works independently in a collaborative environment.
• Cooperates with other personnel to maintain good employee relations.
• Informs supervisor of concerns and problems.

JOB QUALIFICATIONS:

• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems.
• Prior work experience and proficiency with Electronic Health records required.
• Proficient in the use of computers, including Microsoft Word, Excel, PowerPoint, Outlook and other applications necessary to perform daily work, such as an encoder or CDI workflow and reporting tool.
• Requires good interpersonal and communication skills to effectively interact with physicians, patients, families and coworkers.

Licenses/Certifications:

• RN preferred
• Clinical Documentation Specialist credential (CDIP or CCDS) preferred