Clinical Documentation Specialist RN

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.

• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Responsible for the day‑to‑day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• Gather and analyze information pertinent to documentation findings and outcomes

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.

• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Responsible for the day‑to‑day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• Gather and analyze information pertinent to documentation findings and outcomes

Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.

• Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.
• Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation
• Coordinates education to all internal customers related…