Clinical Doc Spclst

Brown Medicine

2d•$86,882 - $173,742•Onsite

About The Position

Under the general supervision of the Manager of Clinical Documentation, the Clinical Documentation Specialist concurrently audits medical record documentation to help evaluate and improve its quality. The role ensures documentation accurately reflects patients’ severity of illness, expected risk of mortality, and complexity of care. The specialist collaborates with physicians, mid-level providers, nursing staff, other caregivers, and coding staff to improve the quality and completeness of documentation and support coding to the highest specificity. The position supports timely, accurate, and complete clinical information used to measure and report physician and facility outcomes. Brown University Health employees are expected to role model the organization’s values of Compassion, Accountability, Respect, and Excellence, and demonstrate the core Success Factors: Instill Trust and Value Differences; Patient and Community Focus; and Collaborate.

Requirements

Current Registered Nurse licensure in Rhode Island through the Rhode Island Board of Nursing or under the Nurse Licensure Compact.
Registered Nurse applicants must have current Rhode Island licensure and 3 years of relevant clinical experience; a BSN is required.
Physician Assistant or Nurse Practitioner applicants must have current Rhode Island licensure and 3 years of relevant clinical experience.
Applicants who successfully completed the education required for a medical degree must have 2 years of clinical documentation experience.

Nice To Haves

Master’s degree preferred.

Responsibilities

Assess documentation, care, and treatment for assigned patient populations using current clinical knowledge.
Identify principal diagnoses, MCCs, CCs, and diagnoses that affect severity of illness, risk of mortality, and risk adjustment.
Concurrently audit medical records on admission and throughout the hospital stay to ensure documentation reflects the patient’s severity of illness, expected risk of mortality, and care.
Analyze the patient’s clinical status, treatment plan, and medical history to identify documentation gaps.
Identify opportunities to clarify incomplete, ambiguous, or conflicting documentation.
Develop concise, effective, compliant written and verbal queries and communicate with physicians and mid-level providers about care as it relates to severity of illness and expected risk of mortality.
Provide just-in-time education to physicians, mid-level providers, and other healthcare team members about documentation requirements.
Identify documentation opportunities that may require formal education and participate in informal and formal education sessions.
Develop proficiency with the 3M encoder and enter diagnoses and procedure codes to assist with assignment of MS-DRG/PR-DRG.
Apply basic HIM coding standards when evaluating medical record documentation and identify the working and CDS DRG based on reviewed documentation.
Maintain the CDI Database to accurately capture pertinent patient information and data.
Perform timely DRG reconciliation to ensure accurate DRGs, principal diagnoses, and secondary diagnoses and procedures are captured.
Communicate with coding staff to resolve discrepancies and enter data reflecting the reconciliation process.
Serve as a clinical liaison between HIM coding staff and physicians or mid-level providers on clinical documentation issues.
Meet established record-review productivity targets: 16–22 reviews per day in years 1–2 and 20–24 reviews per day in year 2 and beyond, with a mix of initial reviews and re-reviews.
Maintain knowledge of current clinical documentation standards and requirements from CMS, The Joint Commission, Rhode Island, and other regulatory or certifying agencies identified by Brown University Health Corporate Compliance.