Clinical Documentation Specialist | Full Time | Day

Summary

The Clinical Documentation Specialist (CDS) has a broad clinical knowledge base and understanding of DRG documentation requirements. The primary purpose of the CDS is to facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record.

The CDS faciliates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff and other caregivers utilizing coding and clinical documentation expertise. The CDS will manage a concurrent query process to accurately capture the appropriate documentation.

The CDS is also responsible for educating all members of the patient care team on appropriate documentation to support the use of hospital resources and the acuity of patients served.

Education

Four years of formal training or education in specialty or related specialty beyond the high school level (e.g., Bachelor's Degree).

Certification, Registration & Licensure

RN preferred. CDIS/CCDS credential is required upon hire or must be obtained as soon as certification eligibility requirements are met by ACDIS.

Experience

Minimum of 4 years of related experience required. Coding knowledge is required. Demonstrated ability to work independently and manage time effectively. Knowledge of Microsoft software required. CDR2 software through the Claro product knowledge preferred.

Responsibilities

• Work product impacts the productivity and quality goals for clinical documentation improvement program.
• Demonstrates knowledge of MS-DRG's/APR-DRGs documentation requirements and guidelines.
• Obtains needed clarification of clinical documentation to ensure documentation is a complete and accurate description of services provided to our patients.
• Identifies trends in documentation opportunities and provides education to appropriate audience to ensure compliance with documentation and coding guidelines.
• Reports ongoing issues and improvement plans.
• Utilizes the software system accurately to track and analyze outcomes of documentation improvement efforts, as well as trend the data.
• Assists to develop and maintain clinical documentation improvement policies and procedures.
• Attends all CDIP meetings and educational sessions and is prepared to discuss trends and findings from daily activities.
• Meets all departmental, professional and technical requirements.

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Physical and Work Requirements

The physical demands and characteristics of the work environment described here are representative of those that will be encountered by an employee to successfully perform the essential functions of this job.

The Dictionary of Occupational Titles Material Handling Classification is SEDENTARY. The employee must regularly lift, carry or push/pull less than 10 pounds, frequently lift, carry or push/pull less than 10 pounds, and occasionally lift, carry or push/pull up to 10 pounds.

• While performing the duties of this Job, the employee is regularly required to sit.
• The employee is frequently required to do repetitive motion, hear, and perform activities that require fine motor skills.
• The employee is occasionally required to bend, climb, kneel, reach, speak, squat, stand, and walk.
• Specific vision abilities required by this job include color vision, depth perception, far vision, near vision, and peripheral vision.

The noise level in the work environment is usually quiet.