Clinical Documentation Specialist II- Full Time Days

Cape Fear Valley Health

34d • Onsite

About The Position

Facilitate clarification to clinical documentation in the medical record; through extensive concurrent reviews with interactions with physicians, nursing staff, other interdisciplinary team caregivers and health information management coding staff, which supports appropriate acuity, resource utilization, quality, severity of illness/risk of mortality (SOI/ROM) and reimbursement. Ensures that clinical severity captured for the level of service rendered to all patients with a DRG based Payor (i.e., Medicare, Medicaid, Commercial, etc.) is accurate. Supports timely, accurate and completed documentation of clinical information, used for measuring and reporting physician and medical center outcomes. On an ongoing basis, CDS will provide educational requirements on clinical documentation to all members of the interdisciplinary care team, while ensuring compliance with regulatory guidelines be maintained.

Requirements

• Associate’s degree in Nursing required
• Current Registered Nurse licensure in North Carolina or compact/multi-state license required
• 5 years of clinical experience in inpatient hospital setting with 1 year of critical care experience (ED, ICU, etc) required
• 2 years of ICD-10 CDIS experience required
• Proficiency in reading, writing, and speaking the English language
• Excellent observation skills
• Critical analytical thinking, problem solving skills
• Verbal and written communication skills
• Basic knowledge of computers, Microsoft Windows software products and keyboarding skills
• Ability to communicate with people from various professions and backgrounds with tact and diplomacy
• Ability to remain calm in stressful situations
• Knowledge of DRG Payor issues, documentation opportunities and clinical documentation requirements
• Flexible with changing workload/assignments
• Demonstrate positive teamwork/interpersonal relations with all members of teams (coworkers, supervisors, physicians, nurses, etc)
• Ability to work with highly sensitive information and materials where confidentiality is of the utmost importance
• Must be able to lift 35 pounds
• RN - Board Of Nursing

Nice To Haves

• Bachelor's degree in Nursing preferred
• Medical/Osteopathic Doctorate (MD/OD) or an international qualified physician (IMD/MBBS) preferred
• Medical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required
• Remote CDS workers must have and maintain secure space and internet connection

Responsibilities

• Identify the most appropriate principle diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulations
• Facilitate modifications to clinical documentation that support the clinical severity of services, clinical validity rendered to all patients with a DRG base Payor (i.e. Medicare, Medicaid, Commercial, etc.)
• Review coding & clinical issues with coding staff to assign the most appropriate working & final DRG
• Complete follow-up/continued stay & potential retrospective reviews of clinical documentation and updates worksheets/findings at least every 24-48 hours or as indicated
• Conduct follow-up/continued stay reviews of clinical documentation to ensure points of clarification documented in the patient’s chart are met
• Confer with physicians face-to-face, via Epic Secure chat, phone and/or via queries to clarify information in medical record, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity of the patient
• Assist with education for all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
• Review charts with Senior Lead CDIS and/or CDIS Director if unable to reach an agreement with Clinical Coding Specialists
• Assists other team members to ensure completion of all work assignments
• Other duties as assigned

Benefits

• Exceptional healthcare
• Caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process
• Improve the quality of every life we touch
• Diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree