Clinical Documentation Specialist

Omega Healthcare Management Services • Boca Raton, FL

5d • Remote

About The Position

The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).

Requirements

• 5 Years of Beside Clinical Nursing experience in Adult Intensive Care Unit, Critical Care Unit, or Medical Surgery Unit.
• Active RN license in the states of IA, WI, IL, or SD or Compact US Nursing License.
• 2 Years of concurrent experience in Clinical Documentation Integrity working with Concurrent Chart Review.
• 2 Years of Epic Experience.
• 2 Years of experience writing providers queries.
• Resume must reflect all required experience.
• Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required

Nice To Haves

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred
• Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Bachelor’s degree, with a healthcare related credential
• Experience with Nuance CDE a plus.

Responsibilities

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.
• Meet CDI program objectives, goals, and balance scorecard metrics.
• Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Ensure effective communications with key stakeholders.
• Analyzes data, creates reports to meet desired outcomes.
• Identifies trends and opportunities for improvement in clinical documentation.
• Meets program quality and productivity guidelines and standards.
• Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.
• Work effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.
• Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
• Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
• Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
• Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
• Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).
• Meets the minimum productivity and quality assurance standards established by the CDI department.
• Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
• Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
• Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.
• Collaborates with other hospital departments as needed and directed by CDI leaders.

Benefits

• Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law.
• Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.
• Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances.
• If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at [email protected]

What This Job Offers

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