Clincal Documentation Specialist (CDS)

Advocate Health • Burlington, VT

1d • $38 - $57 • Hybrid

About The Position

The Clinical Documentation Specialist (CDS) is responsible for conducting initial concurrent reviews for admissions to initiate tracking and identify key pathway or quality indicators. In collaboration with physicians, nurses, and Medical Records coders, the CDS identifies and records principal and secondary diagnoses, principal procedures, and assigns a working Diagnosis Related Group (DRG). The role involves identifying the need to clarify clinical documentation, initiating communication with providers through the query process to capture documentation supporting patient severity of illness, and serving as an educator and resource to medical and hospital staff regarding clinical documentation requirements. The CDS promotes effective professional relationships, identifies and resolves barriers to documentation standards, performs thorough chart reviews to identify and document co-morbidities/complications, utilizes monitoring tools to track the Clinical Documentation Assurance Program, and identifies quality variances. Additionally, the CDS provides information and education to physicians and ancillary staff who do not respond to queries.

Requirements

• Registered Nurse license issued by the state in which the team member practices.
• Associate's Degree in Nursing.
• Typically requires 3 years of experience in an acute inpatient environment.
• Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program.
• Working knowledge of Medicare reimbursement and coding structures.
• Knowledge of care delivery documentation systems and related medical record documents.
• Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.
• Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
• Excellent written and verbal communication and critical thinking skills.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.

Nice To Haves

• Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies helpful.

Responsibilities

• Conducts initial concurrent review process for all selected admissions to initiate the tracking process and identification of other key pathway or quality indicators as appropriate.
• In collaboration with the physician, nurse, and Medical Records coder, identifies and records principle and secondary diagnoses, principle procedures, and assigns a working Diagnosis Related Group (DRG).
• Identifies need to clarify clinical documentation in records, and initiates communication with the provider by utilizing the query process, in order to capture the documentation in the medical record that supports patient's severity of illness.
• Serves as an educator and resource to the medical staff and hospital staff regarding clinical documentation requirements.
• Promotes effective professional relationships with physicians, other department members and hospital staff; facilitates problem solving as appropriate.
• Identifies, evaluates, and acts to resolve any barriers to meeting documentation standards.
• Performs a thorough chart review to identify co-morbidities / complications and documents these appropriately on the clinical documentation worksheet.
• Utilizes monitoring tools to track the progress of the Clinical Documentation Assurance Program.
• Identifies quality variances that can be abstracted concurrently.
• Provides information and education as necessary to physicians and ancillary staff not responding to queries.

Benefits

• Comprehensive suite of Total Rewards: benefits and well-being programs
• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

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