Clinical Documentation Specialist

Summary

The Clinical Documentation Specialist facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care, and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.

Status, Location, Department, Schedule

• STATUS: Full-time
• LOCATION: Remote
• DEPARTMENT: Clinical Documentation
• SCHEDULE: Day shift

Attributes

• Ability to learn/develop the skills necessary to perform the Clinical Documentation Specialist role
• Organizational, analytical, writing, and interpersonal skills
• Dependable, self-directed, and pleasant
• Critical thinking, problem solving, and deductive reasoning skills
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows based software programs
• Knowledge of regulatory environment
• Understand and support Clinical Documentation Specialist documentation strategies (upon completion of training)
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)
• Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
• For Skilled Nursing Facility Only: Understand Medicare Part A guidelines
• Understand the current FY SNF PPS Final Rule
• Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings
• Understand the MDS Resident Assessment Instrument (RAI) Manual
• Ability to use the CMS PDPM Calculator Tool

Minimum Qualifications

• 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.
• Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.
• Previous Clinical Documentation Specialist experience preferred
• For Skilled Nursing Facility Only: 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility
• Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.
• OR a degree in Health Information Management (Associate’s Degree with RHIT; Bachelor’s Degree with RHIA)

Required Licensure/Certification

• RN, PA, NP, MBBS or MD prepared candidates.
• If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire.
• For Skilled Nursing Facility Only: Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA

Responsibilities

• Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety
• Effective and appropriate communication with physicians
• Provides education to members of the patient care team regarding the Clinical Documentation Specialist process.
• Timely follow up on all cases and resolution of those with clinical documentation clarifications
• Actively participate in Team Meetings
• Manage multiple priorities
• Communicates with HIM staff and resolves discrepancies
• Accurate input of data into department software
• For Skilled Nursing Facility Only: Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
• Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
• Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.

Education

LICENSES / CERTIFICATIONS: RN - Registered Nurse - New York State Education Department (NYSED)

Physical Requirements

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

Pay Range

$78,000.00 - $95,000.00 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Key skills/competency

• Clinical Documentation
• Medical Record Review
• ICD-10-CM Coding
• DRG Assignment
• Patient Safety Indicators
• Pathophysiology Knowledge
• Disease Process Understanding
• Healthcare Team Collaboration
• Acute Care Experience
• Registered Nurse (RN)