Clinical Documentation Specialist

Advocate Health • North Wilkesboro, NC

4d • $38 - $57 • Hybrid

About The Position

This is a full-time, hybrid role for a Clinical Documentation Specialist. The position is responsible for facilitating appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. This involves conducting medical record reviews, assigning working MS-DRGs, and querying physicians to ensure documentation is complete prior to coding and billing. The specialist will also review and resolve clinical issues in the pre-bill stage, collaborate with inpatient coding staff, and communicate effectively with case managers, nursing staff, quality and analytics, and other ancillary staff. A key part of the role includes providing education to physicians and other healthcare providers on documentation requirements and guidelines, supporting ICD-10-CM/PCS training, and maintaining awareness of optimal outcomes in CDMP performance and compliance goals. The specialist will analyze clinical status, treatment plans, and medical history to identify documentation gaps, participate in quality assurance, and pursue personal development through continuing education. The role also involves supporting clinical documentation compliance activities, including hospital-acquired conditions, and conducting pre-bill medical record reviews. The specialist will utilize software systems for data collection and ensure data integrity, while also supporting age/developmentally appropriate patient care. This role requires a Registered Nurse license and professional certification in Clinical Documentation is highly recommended within two years of hire. A BSN degree and five years of direct clinical nursing experience are required.

Requirements

• Current license to practice as a Registered Nurse (RN) in the State of applicable state.
• Graduation from an accredited School of Nursing with BSN.
• Five years direct clinical nursing experience required.
• Strong oral, written, listening, and interpersonal communication skills
• Experience in developing and presenting education programs
• Competent computer skills including knowledge of Excel, Microsoft Word, PowerPoint, and Microsoft Outlook
• Analytical skills
• Self-motivated, self-directed and able to work independently with minimal supervision
• Able to work in a collaborative atmosphere
• Ability to accept and incorporate critical comment
• Well organized and detail oriented
• Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions

Nice To Haves

• Professional certification in Clinical Documentation (CCDS) highly recommended within two years of hire.
• Five years direct inpatient bedside experience. Especially with ED, Acute Care, Med Surg, ICU, etc.

Responsibilities

• Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients.
• Follows CDMP processes for conducting medical record reviews, assigning a working MS-DRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation appears in the medical record prior to coding and billing.
• Consistently meets established productivity targets for record review.
• Reviews and resolves any clinical issues arising in the pre-bill stage of medical coding to insure the most accurate DRG has been assigned for billing purposes.
• Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation.
• Prompt and professional interactions are used to effectively to resolve any deficiency.
• Collaborates with case managers, nursing staff, quality and analytics and other ancillary staff as needed regarding interactions with physicians on documentation to resolve physician queries prior to patient discharge.
• Communicates information effectively by responding to questions, concerns and requests promptly.
• Encourages communication by promoting open dialogue.
• Provides one-on-one education to physicians, mid-level providers and other key healthcare providers regarding the need for accurate, specific and complete clinical documentation in the patient's medical record.
• Support ICD-10-CM/PCS training for providers by reinforcing coding conventions and guidelines.
• Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation.
• Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals.
• Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Participates in departmental quality assurance activities.
• Demonstrates responsibility for personal development by participating in continuing education offerings.
• Maintains competence related to MS-DRG assignment, documentation requirements, ICD-10-CM/PCS code assignment and coding guidelines.
• Participates in clinical documentation compliance activities including hospital acquired conditions by assuring accurate documentation resulting in the most appropriate MS-DRG assignment.
• Conducts pre-bill medical record reviews, assuring compliance with coding and documentation guidelines.
• Identifies missed opportunities related to clinical documentation and coding guidelines.
• Seeks additional clarification of documentation from the physician as needed in the post-discharge period in order to ensure the medical record is complete and accurate.
• Follows CDMP procedures for moving medical records through pre-bill process in a timely manner.
• Utilizes software systems to collect and ensure the effectiveness of the data.
• Maintains integrity of data collection by ensuring accurate data entry.
• Demonstrates competence in navigation of software.
• Utilizes software as a resource in ensuring accurate documentation.
• Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served.
• Knowledge of physical, motor/sensory, mental, psychosocial, safety and developmental factors in the Age-Specific Care Guidelines is reflected in reviews of patient medical records and interactions with the multidisciplinary team.

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