Clinical Documentation Spec​/HIM Clinical Document Mgmt

Location Detail

9 Farm Springs Rd Farmington (10566)

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The Clinical Documentation Specialist (CDS) 1 is responsible for extensive record review, and interaction with physicians, HIM coding professionals, nursing staff and other patient care givers to ensure the accurate representation of patient severity of illness and quality of care. The CDS is also responsible for active participation in team meetings and development of clinical documentation guidelines and education of staff on these guidelines on an ongoing basis.

CDS 1 may mentor, train or lead other CDS during their orientation period and assist them with Clinical Documentation Integrity (CDI) policies, procedures, standard work, and systems on an ongoing basis.

• Provides extensive and accurate reviews of medical records within specified timelines.
• Recognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarifications/queries.
• Follows up on all cases especially those with clinical documentation clarifications/queries. Provides education to providers on responding to queries in the medical record and other CDI topics.
• Meets program quality and productivity guidelines and standards.
• Participates in Coding/CDI meetings and CDI H3W work group.
• Inputs review workflows and accurate data and CDI query impact into Optum and EPIC.
• Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment for compliance, reimbursement, and quality outcomes.
• Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI).
• Meets revenue cycle goals, Key Performance Indicators (KPIs), quality and productivity standards.

• An experienced CDS 1 may assist in training and mentoring new CDS’ to become acclimated to new environment, and understanding internal policies, procedures, standard work, and workflows.

• Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory.
• Collaborates with HIM coding staff to resolve discrepancies.

• Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association.
• Participates in other assignments and special projects as assigned.

This Job

Reports To:

HHC Clinical Documentation Manager or Supervisor

• Associates Degree or equivalent experience.

• Registered nurse (RN) with recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), or strong Med/Surg.

or

• Certified Coding professional with 1-2 years CDS experience.

• Minimum: RN and/or Certified Coding Specialist (CCS)
• Preferred:
• Certified Clinical Documentation Specialist (CCDS) certification

or

• Certified Clinical Documentation Professional (CDIP) certification

• Strong written and verbal communication skills

• Ability to learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Knowledge of Pathophysiology and Disease Process.
• Working knowledge of clinical information.
• Ability to understand and communicate the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
• Must be able to function independently.
• Solid analytical capabilities.
• Strong organizational skills.
• Strong critical thinking, problem solving and deductive reasoning skills.
• Ability to handle multiple priorities and increasing responsibility
• Strong ability…