Clinical Documentation Specialist

Best Care • Council Bluffs, IA

2d • Onsite

About The Position

Responsible for concurrent review of clinical documentation for all selected admissions to ensure an accurate representation of the clinical condition of the patient through complete and accurate reporting of diagnoses and procedures.

Requirements

• Graduate of an accredited school of nursing required.
• Five years clinical experience in medical surgical nursing and/or ICU, or case management, and/or inpatient clinical coding, and/or healthcare revenue cycle.
• Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.
• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.
• Develops collaborative relationships with a variety of professionals including physicians.
• Is a self starter and able to deal with resistance and complex situations.
• Ability to foster and attitude of teamwork and trust.
• Functions as an educator and enabler to physicians.
• Must be objective and logical.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.
• Successful completion of annual mandatory education requirements.

Responsibilities

• Performs concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects all disease processes being treated or affecting care while the patient is hospitalized by analyzing documentation for incompleteness, identifying ambiguous, conflicting or clinically incongruent documentation and ensure the documentation supports treatment being provided. 25-30 reviews performed daily.
• Assists with the development of physician queries to ensure compliance with the query process in an effort to obtain the correct clinical diagnoses and capture of severity of illness by incorporating clinical indications and clinical knowledge in the development of the query. Demonstrates knowledge of an appropriate worded query that meets regulatory, legal and ethical standards.
• Initiates assertive professional communication with physicians when documentation is unclear, incomplete or lacks the necessary completeness to assign ICD-10 codes by completing query form or face-to-face communication with the physician. Feedback and/or observation by supervisor of communication approach, clinical knowledge and professionalism.
• Tracks responses to questions on documentation by trending compliance with documentation queries in an effort to identify opportunities for physician feedback and education. Number of MD responses to query. Number of changes to documentation. Principle diagnosis. Secondary diagnosis. Change in Case Mix Index
• Works with coding staff to clarify documentation issues by meeting with the coding staff on a regular basis to ensure understanding of documentation requirements. Feedback from coding staff
• Maintains collaborative relationship with staff nurses, care coordinators, utilization review staff, inpatient coding staff and all hospital and health System personnel. Feedback from staff. Supervisor observation.
• Provide education/training to physicians, physician office staff, nurses and coders in a variety of settings: One on one; Group presentations and Quick sessions during rounds. Presentation skills. Presentation materials. Evaluations from participants.
• Works in partnership with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

Benefits

• competitive pay
• excellent benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level