Clinical Documentation Specialist Ii

ECU Health

About ECU Health

ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.

The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children’s Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.

Position Summary

Facilitates appropriate Clinical Documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Accurately identifies physician query opportunities.
Stays current with and conducts on-going Clinical Documentation management program education for new staff, including new Clinical Documentation Specialists, physicians, nursing and allied health professionals.
Collaborates effectively with departmental/program staff to achieve goals and objectives.
Demonstrates acceptable level of value based behaviors
Facilitates concurrent performance improvement activities

Responsibilities

Facilitates appropriate Clinical Documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
Analyzes data and reports quality issues to Supervisor and/or Manager.
Records appropriate admission status, working DRG & LOS info in CDI Tracking tool.
Comprehensively reviews all physician and Clinical Documentation, lab results, diagnostic information, and treatment plans and accurately identifies physician query opportunities. Creates appropriate and compliant queries.
Reviews medical record every 24-48 hours as appropriate for changes in clinical condition or to ensure issues discussed and clarified with the physician have been documented in patient's chart.
Updates CDI Tracking tool to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate for intradepartmental communication.
Collaborates with coding staff, as needed, to determine appropriate DRG and required documentation.
Utilizes clinical skills to identify documentation opportunities that reflect PDx, comorbid conditions, complications, procedures, severity of illness, Risk of mortality, PSIs, acuity and resource consumption.
Performs concurrent education of physician and staff regarding best practice.
Stays current with and conducts on-going Clinical Documentation management program education.
Attends and participates in educational conferences
Participates on departmental and house wide committees as appropriate.
Provides overview of Clinical documentation Improvement to new staff, including physicians and other members of the interdisciplinary team.
Effectively communicates with physicians and other members of the interdisciplinary team to clarify potential documentation opportunities.
Provides clinical expertise and references to the coding staff.
Communicates with physician to ensure that request for documentation has been noted.
Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
Follows established guidelines for reconciling final coded DRG assigned at the time of discharge.
Facilitates concurrent performance improvement activities.
Demonstrates acceptable level of Value Based behaviors.
Follows Patient Safety guidelines, organizational policies and procedures, professional standards of care, best practices, and regulatory requirements related to patient care quality.
Consistently uses good judgment and thinks critically in order to make correct decisions.
Collaborates effectively with departmental/program staff to achieve goals and objectives.
Delegates appropriately to maximize skill set, productivity and effectiveness.
Educates the interdisciplinary team regarding coding, documentation and quality.
Participates in special projects, and/or hospital committees pertaining to CDI initiatives.
Identifies strategies to evaluate and modify the Clinical Documentation program.
Maintains productivity and optimum client caseload for position.
Analyzes data and reports quality issues to Supervisor and/or Manager and submits all departmental reports in a timely manner.
Attends department/program meetings regularly.

Minimum Requirements

ADN, BSN, MD or equivalent is required
3 years recent CDI experience is required
Certification (CCDS or CDIP required)

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

Contact Information

For additional information, please contact:

Angie Nichols, Talent Acquisition Consultant

ECU Health Talent Acquisition

Email: Angie.Nichols@ecuhealth.org