Clinical documentation improvement specialist job description

Complete and accurate diagnostic and procedural coded data is necessary for communication of patient's treatment plan, evaluation of the quality of care rendered, reimbursement, financial and strategic planning, outcomes and statistical analyses, epidemiology and research. Clinical Documentation Specialist must meet the challenges of contributing to an accurate and meaningful database that clearly defines both the patient mix and the use of resources. Assuring the accuracy of coded data is a shared responsibility between the Clinical Documentation Specialist, Health Information Management professionals and clinicians.
At least one of the following is required - Registered Medical Coder, CoderRHIA, RHIT, CCS

Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.

Minimum of 4 years' experience in an acute adult in-patient with demonstrated critical thinking skills OR a minimum of two years' experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience. Certified Clinical DocumentationImprovement Specialist (CCDS) or Certified Documentation Improvement (CDI).

Knowledge of concurrent coding and documentation improvement, preferred.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

MC: Clinical Documentation Improvement- ( Full-Time. Day Job )

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.

The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity. Performs other duties as needed.

Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided. Minimum three years of acute hospital nursing or acute hospital coding experience required. For nurses filling role one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred. For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.
California Registered Nurse (RN) License required for nurse filling role.

Recent experience as acute hospital utilization reviewer or Case Manager with knowledge of third party reimbursement requirements preferred. Able to read; write legibly; speak in English with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; performs basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place or patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch.

Additional Information

* Organization: Loma Linda Univ Medical Center
* Employee Status: Regular
* Schedule: Full-time
* Shift: Day Job

Educate providers on effectively documenting the patient's severity of illness, physician clinical judgment and medical decision making in support of medical necessity and appropriate CPT and diagnosis coding.
Principal Duties & Responsibilities:

1. Review of patient health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.

2. Educate providers on how to document continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the "progress" of the patient.

3. Train providers on how to facilitate complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient's primary care physician.

Knowledge, Skills & Abilities:

Required:

* Strong clinical documentation knowledge, to completely and accurately report on patient services provided.
* Knowledge of ICD-10-CM, CPT and HCPCS Official Coding Guidelines.
* General knowledge of what constitutes a complete and accurate record-i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
* Practical knowledge and understanding of official E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity.
* Effective ability and willingness to communicate benefits of complete and accurate documentation to providers relating to their daily practice of medicine.
* Commitment to maintain knowledge in and familiarity of constantly changing updates in the business of medicine directly impacting the practice of medicine and providers.
* Demonstrated understanding of documentation relevant to denial avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs.
* Ability to review medical necessity denials and provide constructive feedback to providers.
* Ability to work with all provider specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each provider on an "as you go" basis.
* Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame.
* Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed.
* Flexibility and ability to adjust to a constantly changing work environment
* Adheres to clinic's policies and procedures

Education:

RHIT and clinical license or/certification required; CCDS and/or CDS preferred.

Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD10 and ability to educate physicians on the merits of preparation as the best practice strategy in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician's, updates from CMS carriers effecting physicians such as billing, documentation, and coding guidelines and policies.