HIM Clinical Documentation Specialist

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The Clinical Documentation Specialist will be responsible for supporting an organization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians for complete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and a compliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related.

Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilize compliant questions and tools toward a complete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection.

• Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines
• Provide clinical care teams with ongoing education and training on current trends in documentation and coding
• Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department
• Enter clinical review data and related anticipated follow-up in EPIC PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG
• Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity
• Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system
• Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory time frames
• Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation
• Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation
  
  Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed
• Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation
• Proficient in negotiating complex systems to effect positive change
• Ability to interpret, adapt, and apply guidelines and procedures
• Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems
• Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
• Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
• Serve as a resource on DRG issues
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
• Other duties as assigned to support the unit, department, entity, and health system organization

• RHIA, RHIT, and CCS certifications are preferred.
• CCDS or CDIP is preferred.
• RN, NP, or PA…