Clinical Documentation Specialist

Major Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidence 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.

• 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 to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff.
• Maintains knowledge of current standards of care via literature review and participation in educational offerings.
• Research literature to identify new methods development and overall documentation enhancement.
• Complete required contact hours based on FTE status, within time frame.

• Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.
• Completes documentation on reviewed cases in the database.
• Completes the DRG and query indicators for each reviewed case, as appropriate.
• Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.
• Identify patterns, trends variances and opportunities to improve documentation review and process.

• Maintains a positive attitude about assignments and team members.
• Promotes professional/personal growth of co‑workers by sharing knowledge and resources.
• Manages stress and personal feelings without a negative impact on the team.
• Communicates in a positive and productive manner.
• Demonstrates flexibility with changing workload/assignments.

Registered Nurse (RN). Current nursing license in the State of Illinois.

Graduate from an accredited school of nursing. BSN. 5 years relevant clinical experience (for associates in process level…