Clinical Documentation Specialist

10169 Enterprise Corporate
- Clinical Documentation Improvement

10169 Enterprise Corporate
- Clinical Documentation Improvement

Full time

Yes

40

Full-time, dayshift Monday
- Friday, This role will be hybrid with one day per week onsite.

No relocation and no sponsorship or transfer of visa for this position now or in the future.

$38.20 - $57.30

• Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. Follows CDMP processes for conducting medical record reviews, assigning a working MS-DRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation appears in the medical record prior to coding and billing. Consistently meets established productivity targets for record review.
• Reviews and resolves any clinical issues arising in the pre-bill stage of medical coding to insure the most accurate DRG has been assigned for billing purposes. Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation. Prompt and professional interactions are used to effectively to resolve any deficiency.
• Collaborates with case managers, nursing staff, quality and analytics and other ancillary staff as needed regarding interactions with physicians on documentation to resolve physician queries prior to patient discharge. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages communication by promoting open dialogue.
• Provides one-on-one education to physicians, mid-level providers and other key healthcare providers regarding the need for accurate, specific and complete clinical documentation in the patient's medical record. Support ICD-10-CM/PCS training for providers by reinforcing coding conventions and guidelines.
• Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation. Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation. Participates in departmental quality assurance activities.
• Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MS-DRG assignment, documentation requirements, ICD-10-CM/PCS code assignment and coding guidelines.
• Participates in clinical documentation compliance activities including hospital acquired conditions by assuring accurate documentation resulting in the most appropriate MS-DRG assignment. Conducts pre-bill medical record reviews, assuring compliance with coding and documentation guidelines. Identifies missed opportunities related to clinical documentation and coding guidelines. Seeks additional clarification of documentation from the physician as needed in the post-discharge period in order to ensure the medical record is complete and accurate.
  
  Follows CDMP procedures for moving medical records through pre-bill process in a timely manner.
• Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.
• Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served.…