Clinical Documentation Specialist Ii

Works with physicians and other patient care providers to improve the quality of chart documentation to accurately reflect intensity of service and severity of illness. Works collaboratively with coding staff. Utilizes monitoring tools to track the progress of the documentation accuracy program. Provides education and feedback to the medical staff one-on-one and in-group settings regarding documentation. Reports activities monthly to the Clinical Documentation Improvement Committee.

JOB DUTIES

• Demonstrates behaviors consistent with identified competencies and job requirements Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other patient care providers to improve the quality of chart documentation to accurately reflect level of services provided.
• Performs initial case reviews and appropriate follow-up reviews based on judgment of clinical picture.
• Performs concurrent review of all components of the medical records of specified patient population to include assignment of DRG, identifying complications and co morbid conditions, and specific co-existing conditions.
• Documents findings in appropriate format based on need to communicate the information to the medical staff or coding.
• The format may include any or all of the following: DRG worksheets, Occurrence Reporting System focus study entries, coding and reimbursement preliminary attestation sheets and queries.
• Accurately interprets clinical information in the medical record including diagnostic tests, medications, procedures, and nursing assessments. Assists in the research and development of evidence-based physician order sets and protocols.
• Proficient in accessing multiple software systems and integrating data from all systems including Occurrence Reporting System application, Electronic Medical Record, and the Coding and Reimbursement software.
• Performs other duties consistent with purpose of job as directed.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Education: Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.

Licensure: Must possess one of the below:

• Current Registered Nurse License in the State of practice,
• Registered Health Information Administrator (RHIA),
• Registered Health Information Technician (RHIT),
• Certified Coding Specialist (CCS) required,
• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.

Experience: Two (2) years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.