Clinical Documentation Specialist

UNC Health • Goldsboro, NC

103d

About The Position

The Clinical Documentation Specialist analyzes the medical record for the clinical status of the patient, current treatment plan, and care provided on admission and throughout hospitalization to identify potential gaps in physician documentation. The specialist tracks the progress of documentation improvement and works collaboratively with the healthcare team to facilitate documentation within the medical record that accurately reflects the patient's condition, severity of illness, risk of mortality, services rendered, and medical necessity of resources used.

Requirements

• B.S. Degree in nursing preferred.
• North Carolina Registered Nurse Licensure.
• Minimum of 2 years' experience in CDS role in an acute care facility or coding certification of CCS, CCA, RHIT, or RHIA required.
• Minimum of 3 years' experience in acute care (hospital) setting required.
• Medical/Surgical or critical care experience preferred.

Nice To Haves

• Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs.
• Understanding of coding classification systems (ICD-9, ICD-10, CPT, HCPCS).
• Clinical knowledge to read and analyze a patient's health record.
• Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes.
• Strong analytical skills.
• Ability to collaborate and communicate with physicians, nursing, and other patient care teammates.
• Ability to read, write and communicate effectively in English.
• Proficient with MS Office and able to learn new software rapidly. Experience with EPIC EMR software preferred.

Responsibilities

• Reviews documentation and communicates with physicians verbally or through compliant query practice to clarify diagnosis, severity of illness, plan of care and opportunities for more complete documentation to accurately reflect care.
• Collaborates closely with healthcare team and coding staff to assure documentation of diagnoses and any co-morbid conditions are complete, reflecting patient's clinical status and care. Follows up on pending queries and updates electronic worksheets as needed.
• Works with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units.
• Utilizes the guidelines established to recognize opportunities for improvement in Clinician documentation, and to formulate and generate clear, compliant and concurrent questions to those Clinicians.
• Utilizes inpatient admission criteria to assign diagnoses that meet acute care criteria. In the event that diagnosis does not meet admission criteria, communicates directly with attending physician.
• Conducts initial and extended-stay concurrent reviews on all selected admissions, consistently meeting established productivity targets for CDI record review.
• Informs direct supervisor or indirect supervisor of issues or problems that may compromise policy, procedure, compliance or the Hospital Ethical Code of Conduct.
• Utilizes designated and approved tools to track progress, physician participation and feedback.
• Queries the medical staff and other caregivers as necessary via electronic/verbal communication to obtain accurate and complete physician documentation to supports the severity of patient illness and risk of mortality.
• Monitors documentation for compliance with core measure and reviews targeted diagnoses for appropriateness and completeness. Gathers data and initiates feedback to appropriate personnel.
• Attends annual review and departmental in-services, as appropriate.
• Identifies areas of focus through data analysis and report review.
• Educates members of the patient care team on documentation guidelines on an ongoing basis.

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree