Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) improves the accuracy and completeness of clinical documentation in medical records by performing thorough reviews and requesting clarifications from clinicians. They facilitate modifications that accurately reflect patient severity, risk, and resource use, collaborating with clinicians and coders. The CDS ensures compliance with regulatory guidelines and supports accurate reporting of provider and hospital outcomes. They actively contribute to operational improvements and participate in education and program-related activities, aligning with FMOLHS Mission values.

• 1. Documentation Review
  • a. Performs assigned CDI reviews of inpatient medical records with concentration on review priority as designated (such as those payors with prospective payment methodology).
  • b. Performs accurate and thorough initial and follow up CDI medical record reviews as assigned, within productivity standards.
  • c. Documents CDI review findings, following processes and guidelines.
  • d. Submits queries to physicians, seeking clarity on significant diagnoses, procedures, complications and/or co-morbidities, as indicated, in order to facilitate a comprehensive, clear and complete medical record.
  • e. Consistently demonstrates accurate data entry regarding CDI activity, contributing to efficiency and accuracy of CDI metrics and initiatives.
• 2. Quality
  • a. Operates within the compliance guidelines of Medicare and Medicaid Services.
  • b. Considers compliance and displays ethical decision-making skills.
  • c. Understands and complies with policies and procedures related to confidentiality of medical records.
  • d. Demonstrates actions consistent with FMOLHS Mission, core values and service standards as daily duties are performed.
  • e. Demonstrates standards of performance that support patient satisfaction, principles of service excellence, all applicable laws, regulatory agencies and accrediting bodies.
  • f. Facilitates accuracy and completeness of documentation used for measuring and reporting provider and hospital outcomes.
  • g. Maintains accurate and complete record review and query outcome to comply with departmental and regulatory guidelines.
• 3. Collaboration
  • a. Collaborates with physicians and other clinical disciplines to clarify clinician documentation, which is incomplete, conflicting, or non‑specific.
  • b. Educates physicians and other clinical disciplines on best documentation practices, in conjunction with CDI and Coding leadership, as well as physician advisors.
  • c. Serves as a resource to clinicians for linking medical terminology and coding guidelines for improved accuracy in code assignment.
  • d. Assists with communication between coders and physicians for retrospective querying.
  • e. Collaborates with Health Information Management regarding coding analysis and education initiatives for physicians and other clinical disciplines.
  • f. Consults with leadership and/or other clinical disciplines in matters of uncertainty.
  • g. Demonstrates standards of performance that support patient satisfaction and principles of service excellence.
  • h. Communicates effectively with other team members, physicians and customers while always remaining tactful and friendly.
  • i. Participates in CDI program related meetings, clinician education, staff development, departmental activities, and opportunities.
• 4. Research / Knowledge
  • a. Demonstrates knowledge of ICD‑10 Official Coding Guidelines, and ability to interpret documentation for appropriate working codes, resulting in the correct working DRG assignment.
  • b. Demonstrates ability to interpret medical record documentation to determine the appropriate principal diagnosis and procedure, resulting in the appropriate DRG.
  • c. Demonstrates ability to correlate clinical information/ detail and medical record documentation terminology for appropriate documentation clarification opportunities.
  • d. Demonstrates knowledge of diagnosis specificity clarification opportunities, which could result in greater specificity and accuracy in code assignment.
  • e. Initiates appropriate and accurate documentation clarification requests (queries), facilitating modifications to the medical record…