Clinical Document Specialist, Clinical Documentation Management

at  RWJBarnabas Health

The Clinical Document Specialist is responsible for ensuring accurate and compliant physician documentation in the electronic medical record. When Physician Documentation is accurate and compliant it increases reimbursement, improves quality outcomes and allows for disease tracking/trending.

QUALIFICATIONS:

Required:

• Must be a graduate from an accredited school of nursing
• Must read, write, and speak English
• Must be able to work fully onsite
• Prior experience in clinical documentation review preferred as well as an understanding of ICD-9-CM coding requirements
• Passing grade on JATA clinical test
• Minimum 2 years acute hospital experience as a clinical nurse
• Successful completion of site personnel general orientation
• Successful completion of department specific orientation

Preferred:

• Supervisory experience (in any discipline)

SCHEDULING REQUIREMENTS:

• Full Time
• Day shift
• Monday Friday
• No Holidays
• Hours 7a-3p / 7:30a 3:30p / 8a-4p

ESSENTIAL FUNCTIONS:

The Clinical Documentation Specialist (CDS) responsibilities include assisting in clarifying documentation regarding the patient s diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements. Clarifications will be completed by utilizing computer software to generate the clarification. A clarification is defined as a question posed to a physician to obtain additional documentation to improve the specificity and completeness of the chart documentation elements used to assign diagnosis and procedure codes or other reportable data elements within the health record.
A physician clarification is recommended when an inpatient medical record has incomplete, inconsistent, unclear, ambiguous or conflicting documentation.
Clarifications should be written in the following situations:
Clinical indicators of a diagnosis are present, but there is no documentation of the condition
Will offer multiple choices within the clarification
Clinical indicators or evidence for a higher degree of specificity or severity (SOI; ROM)
A cause-and-effect relationship between two conditions not documented
The underlying cause when admitted with only symptoms
A treatment is documented without a diagnosis documented
Present on admission (POA) indicator status is not well-defined
Acuity of conditions (acute, chronic, acute on chronic)
Conflicting documentation between the attending physician and other healthcare providers
The physician clarification will:
Not lead the physician to a particular, desired response or introduce any new information
Be clearly and concisely written - contain precise language as directed by J A Thomas - The Guide.
Present facts from the medical record and identify why the clarification is needed
Capture Severity of Illness (SOI) and Risk of Mortality (ROM)
Present multiple options
Utilize a 360 degree approach including: clinical indicators; treatment; and risk factors
All questions posed to the provider will be based on clinical indicators, risk factors, and treatment/management to ensure compliance and consistency of policy and process. All physician clarification responses must be documented in a primary source of documentation. Sources of documentation are: the face sheet, H and P, consultation notes, progress notes, and discharge summary.

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.