CLINICAL DOCUMENTATION SPEC

Premier Health • Dayton, OH

1d

About The Position

The Clinical Documentation Specialist facilitates accurate, complete, and compliant medical-record documentation so that each patient’s severity of illness, services provided, and quality of care are accurately represented. The role uses clinical expertise to review records, clarify diagnoses, support accurate coding and DRG assignment, and promote documentation practices that comply with applicable regulations and guidelines.

The specialist works collaboratively with physicians, nursing and ancillary staff, and coding professionals. Responsibilities include concurrent and post-discharge record review, clinically based documentation queries, provider education, and participation in quality and performance-improvement activities. The position also supports departmental goals, maintains required training and competencies, protects patient confidentiality, and demonstrates Premier Health’s expectations for teamwork, communication, compassion, accountability, and service excellence.

Requirements

• Bachelor’s degree required; the posting also specifies a BSN as required.
• Area of study in Nursing, Health Information Management, or as a medical college graduate.
• Current license to practice professional nursing in Ohio or reciprocal states, or USMLE/ECFMG certification for foreign-trained graduates, as applicable; the posting also specifies a valid Ohio Registered Nurse license.
• Three to five years of related experience required; another section specifies a minimum of three years of relevant clinical experience in the patient population area within the last five years.
• Strong critical-thinking, problem-solving, and analytical skills, including the ability to integrate knowledge.
• Interpersonal skills to build and maintain rapport with physicians, peers, and other healthcare team members.
• Negotiation, conflict-resolution, and assertive communication skills.
• Ability to multitask and work effectively with interruptions.
• Teamwork orientation, professionalism, tact, and diplomacy.
• Strong organizational and prioritization skills.
• Effective oral and written communication skills.
• High degree of confidentiality.
• Basic computer skills and knowledge.
• Broad clinical knowledge to review a wide variety of medical records.
• Proficiency in EPIC, 3M, Midas, CDE One, and related software programs.
• Knowledge of ICD-10 coding.
• Computer skills are expected.
• The posting states both that a bachelor’s degree is required and that a Bachelor of Science in Nursing, Health Information Management, or equivalent medical degree is preferred.

Nice To Haves

• Bachelor of Science in Nursing, Health Information Management, or equivalent medical degree.
• Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) certification.
• Previous experience as a nurse, coder, or medical college graduate.
• Certification in clinical documentation, CPHQ, or Case Management.
• Solid working knowledge of healthcare reimbursement.

Responsibilities

• Analyze clinical documentation for assigned patients and recommend appropriate DRG assignment.
• Facilitate documentation that supports accurate diagnosis coding and fully records the level of service provided.
• Complete admission reviews, evaluating principal diagnosis, complicating conditions, and supporting documentation to reflect severity of illness in compliance with government regulations.
• Identify documentation clarification opportunities and complete clinically based queries.
• Follow up promptly on outstanding queries and document outcomes appropriately.
• Prioritize work effectively while meeting employment policies and productivity expectations.
• Participate in departmental goals, metrics, required training, competencies, and educational assignments.
• Support the professional development of peers, care team members, and orientees, and participate in performance-improvement activities.
• Complete initial and follow-up medical-record reviews, considering admission notes, medical history, medications, provider documentation, treatments, orders, ancillary notes, and laboratory data.
• Analyze and interpret clinical data to identify documentation gaps, inconsistencies, and improvement opportunities through the concurrent query process.
• Formulate credible clinical documentation clarifications concerning principal diagnosis, comorbidities, POA status, quality core measures, and PSIs.
• Assign appropriate DRG/APR-DRG, MCCs, and CCs in the CDI documentation system using coding rules and guidelines.
• Educate providers regularly about the Clinical Documentation Improvement program.
• Collaborate with clinical disciplines and coding staff to promote high-quality documentation and timely coding.
• Conduct post-discharge reviews comparing CDI Specialist and Coding DRG assignments.
• Develop collaborative relationships and promote teamwork with coworkers and other departments.
• Organize and perform work responsibilities effectively and efficiently.
• Maintain patient confidentiality in accordance with HIPAA guidelines.
• Demonstrate Premier Health’s strategic goals and behavioral expectations, including teamwork, communication, compassion, accountability, and service excellence.

What This Job Offers

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