Clinical Documentation Specialist - Revenue Cycle Mid Service *Days - 40hrs/wk
Requisition #: req11177
Shift: Days
FTE status: 1
On-call: No
Weekends: No

GENERAL SUMMARY:

The Clinical Documentation Specialist is responsible for reviewing the patient medical record for overall quality, integrity and completeness of clinical documentation. This position facilitates clarifications of clinical documentation through extensive concurrent review of the medical record. Interactions with physicians, nursing staff, other patient caregivers, and coding staff is necessary to ensure accurate inpatient coding and legitimate DRG assignment for the level of service rendered to all patients.

Requirements:

• Licensed as a Registered Nurse in the State of Michigan; BSN preferred
• 5 years of recent clinical experience in a hospital setting required; preferred experience includes critical care, utilization review, coding
• Knowledge of and skill in the use of computers and related systems and software preferred
• Knowledge of medical terminology, as well as patient medical records required
• Skill in observation, analytical thinking, and problem solving required
• Skill in good interpersonal, oral, and written communications, required
• Ability to maintain confidentiality of privileged patient and department information required
• Ability to be persistent in working through and/or resolving issues and problems required
• Ability to work independently and professionally, set priorities and take initiative while working efficiently and using good judgment required

• Initiates and performs admission and concurrent documentation review of selected inpatient records to clarify conditions / diagnoses and procedures where inadequate or conflicting documentation exist. Retrospective reviews may also be performed at the request of hospital administration and coding personnel.
• Demonstrates knowledge of MS-DRGs, documentation opportunities, and clinical documentation requirements. Serves as a resource for physicians to help link coding guidelines and medical terminology to improve accuracy of final code assignment.
• Communicates with the individual physician(s) or medical staff departments to facilitate complete and accurate documentation of the inpatient record to accurately reflect and report the patient’s severity of illness equating to intensity of service.
• Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Works collaboratively with Health Information Management (HIM) department by concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment. Assists the HIM department in facilitation of the physician query process.
• Assists with management of reports from the software tracking tool.
• Other duties as assigned.
• Predictable and reliable attendance.
  

  RN, Category: Nurse