Clinical Documentation Specialist

Overview

The Clinical Documentation Specialist will work with Senior Director in physician education regarding documentation that meets severity of illness/intensity of service guidelines.  The CDS will work with hospital top DRG’s to insure that documentation is optimal and meets coding clinic guidelines in order insure optimal hospital reimbursement.  Prepares and presents reports pertinent to improvements and educational outcomes. 

Responsibilities

• Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses.
• Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record.
• Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.
• Performs a thorough chart review to determine the appropriate principal diagnosis of the patient.
• Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.
• Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
• Maintains flexibility and prioritizes daily responsibilities.

Qualifications

• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
• Assertive personality traits to facilitate ongoing physician communication
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Ability to stand and walk in the performance of job responsibilities.
• Current MD/MBBS
• CDI/Coding experience preferred, but not required