Clinical Documentation Specialist

Clinical Documentation Specialist at Northwell Health

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. This role is responsible for concurrent inpatient medical record reviews for Medicare, Medicaid, and all commercial payers. The Clinical Documentation Specialist generates queries and engages in follow-up discussions with physicians for clarification of ambiguous or conflicting documentation.

Job Responsibilities

• Facilitates clarification of clinical documentation, ensuring accuracy and integrity in the medical record.
• Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded.
• Works with physicians on assigned patient care units to clarify clinical documentation in the patient’s medical record through a concurrent review process throughout the patient’s inpatient stay.
• Requests clarification of clinical documentation from physicians on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge.
• Ensures the level of service rendered to patients and the patient’s severity of illness is accurately documented and recorded.
• Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record.
• Interacts with physicians as needed to discuss and advise on clinical documentation requirements, providing timely and accurate responses to clinical documentation and coding questions.
• Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Reconciles reviewed cases to update any changes in status, procedures/treatments, and confers with providers to finalize diagnoses.
• Educates medical staff on clinical documentation opportunities that impact the accuracy of the medical record.
• Inputs outcome data into the CDI software to track response to queries.
• Responsible for file maintenance, including entry into a database for tracking and trending audit results.
• Communicates findings of potential or missed diagnoses and their revenue impact discovered during chart audits.
• Regularly exercises independent judgment on matters of significance within defined procedures to determine appropriate actions/approaches.
• Understands department, division, and corporate strategy and operating objectives, including their impacts.
• Normally receives general instructions on routine work and detailed instructions on new projects or assignments.
• Majority of contact is within own function, area, or department and may be customer service oriented.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions.

Job Qualifications

• Graduate from an accredited School of Nursing required.
• Must obtain a Bachelor of Science in Nursing degree within 5 years of employment date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed (CCDS, CDIP, or CCS).
• 1-3 years of relevant experience, required.
• Vizient experience, preferred.

Key skills/competency

• Clinical Documentation Improvement (CDI)
• ICD-10 CM/PCS Coding
• MS-DRG/APR Grouper Logic
• Physician Querying
• Medical Record Review
• Compliance Regulations
• Healthcare Revenue Cycle
• Clinical Acuity
• Communication Skills
• Data Analysis