Clinical Documentation Specialist


    • Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes.
    • Collaborate with physician, physician extender, nurse, case manager and Health Information Management coder to identify areas for improved physician documentation.
    • Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracking process.
    • When a need to clarify documentation in the records is identified, individual must utilize assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation. Must work collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality in compliance with all guidelines and requirements.Follow thru to obtain response to physician queries.
    • Utilize monitoring tools to track the progress, monitoring reports and data. Communicate findings with appropriate management staff. Able to identify areas of focus through report analysis.
    • Must possess a current, valid RN ; a graduate of a foreign medical school would also be considered.
    • Minimum of 3 years clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred.
    • Familiarity with coding concepts and coding software desired.
    • Knowledge of care delivery documentation systems and related medical record documents.
    • Knowledge of age-specific needs and the elements of disease processes and related procedures.
    • Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
    • Excellent written and verbal communication skills.
    • Excellent critical thinking skills.