Clinical Doc Spclst

Summary

Under general supervision of the Manager of Clinical Documentation, the Clinical Documentation Specialist is responsible for concurrent auditing of medical record documentation to assist with evaluating and improving the quality of clinical documentation of services to accurately reflect severity of illness, expected risk of mortality, and complexity of care of the patient. The role communicates and collaborates with physicians, mid‑level providers, nursing staff, and other patient caregivers to improve quality and completeness of documentation and with the coding staff to ensure patient documentation is coded to the highest specificity.

The specialist supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

• Demonstrates a thorough and current knowledge of clinical care and treatment of assigned patient population to critically assess appropriateness of documentation, care, and treatment.
• Identifies PDX, MCCs, CCs, and diagnoses that impact SOI, ROM, and risk adjustments.
• Audits the medical record on admission and throughout the hospital stay to ensure documentation reflects the patient’s severity of illness, expected risk of mortality, and care.
• Analyzes the patient’s clinical status, treatment plan, and past medical history to identify potential gaps in documentation.
• Identifies opportunities to clarify incomplete, ambiguous, or conflicting documentation.
• Develops concise, effective, and compliant written and verbal queries.
• Communicates with physicians and mid‑level providers to discuss the patient’s care as it relates to severity of illness and expected risk of mortality.
• Provides just‑in‑time education to physicians, mid‑level providers, and other healthcare team members regarding documentation requirements.
• Identifies documentation opportunities that may require formal education and participates in informal and formal education sessions.
• Develops proficiency with the 3M encoder and accurately enters diagnoses and procedure codes to assist with assignment of MS‑DRG, PR‑DRG, and DRG.
• Applies basic knowledge of HIM standards of coding to ongoing evaluation of medical record documentation.
• Accurately identifies the working and CDS DRG based on documentation reviewed.
• Maintains the CDI database for accurate capture of pertinent patient information and data.
• Performs effective and timely DRG reconciliation to ensure the most accurate DRG, principal diagnosis, and all appropriate secondary diagnoses and procedures are captured.
• Communicates with the coding staff to resolve discrepancies and accurately records the reconciliation process.
• Acts as a clinical liaison between the HIM coding staff and physicians or mid‑level providers regarding clinical documentation issues.
• Consistently meets established productivity targets for record review: year 1–2, 16–22 reviews per day; year 2+, 20–24 reviews per day.
• Maintains knowledge of current standards and requirements for clinical documentation as defined by CMS, the Joint Commission, the State of Rhode Island, and other regulatory or certifying agencies.

• Licensure as a Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
• Registered nurse with current licensure to practice in the State of Rhode Island, 3 years of relevant clinical experience (BSN required, master’s degree preferred), or Physician Assistant or Nurse Practitioner with current licensure to practice in the State of Rhode Island and 3 years of relevant clinical experience, or successful completion of education required for a medical degree with 2 years of clinical documentation experience.

$86,881.60 – $

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Corporate Headquarters – 15 LaSalle Square, Providence, Rhode Island 02903
Work type:
Monday–Friday, 8:00am–5:00pm

Work shift:

Day
Daily hours: 8 hours
Driving required:
No