Clinical Documentation Specialist

Duration: 3 Months

Clinical Documentation Specialist with at least 3 years experience

RHIA/RHIT/Cert. Coder (Associates Degree in HIM required; Bachelor’s degree in HIM highly preferred) OR Registered Nurse (ADN required; BSN highly preferred)

A minimum of 3 years of experience in area of population to be served is required

3 years pervious acute hospital inpatient coding experience highly preferred

Current Texas and/or Louisiana RN license required for RN OR

RHIT or Certified Coding Specialist required for HIM; RHIA preferred

Certified Clinical Documentation Specialist (CCDS) highly preferred

Health Informatics / CORPORATE DIV NP

Quantity: 1

Assignment Start Date: 05/24/2021

Assignment Length: 12 Weeks

Monday-Friday 8 hour days

The PRN Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The PRN CDS will provide support and expertise on a temporary basis through comprehensive assessment and review of inpatient medical records. The PRN CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement (reflecting proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.

MAJOR RESPONSIBILITIES

• Performs concurrent and retrospective reviews of the medical record utilizing evidence-based knowledge, protocols and criteria.
• Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensuring appropriate reimbursement is received for the level of service rendered to all patients.
• Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
• Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
• Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
• Demonstrates familiarity with MS-DRG/APR-DRG’s and Inpatient Prospective Payment System (IPPS).
• Completes initial reviews of patient records to evaluate documentation to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness.
• Completes follow-up reviews.
• Reviews a minimum of standard charts per day as directed.
• Analyzes clinical information. Formulates appropriate clinical documentation clarifications to improve documentation. Queries and educates physicians and key healthcare providers regarding clinical documentation improvement.
• In conjunction with CDI leadership, tracks response to clinical documentation and trends in CDI metrics.
• Maintains and enhances current medical, coding and CDI knowledge by participating in continuing education offerings.
• Consistently meets established productivity targets for record review.
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
• Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.

POSITION SPECIFIC COMPETENCIES

• Strong clinical knowledge and understanding of pathology / physiology of disease processes
• Excellent interpersonal skills to build excellent relationships with physicians, nurse, staff and to be able to educate them
• Must work independently and manage goal productivity; must be efficient and accurate in performance
• Working knowledge of MS-DRG and APR-DRG highly preferred
• Must be familiar with the other functions in Medical Records and how they relate to the Coding function
• Must be able to read and decipher handwriting that is difficult to read

Experience Required: 3+ years.

Shift: Day