Highest Education Level Preferred:
Degrees and Majors:
Bachelors in Nursing (Preferred) General Summary:
The Clinical Documentation Specialist is responsible for reviewing the patient medical record for overall quality, integrity and completeness of clinical documentation. This position facilitates clarifications of clinical documentation through extensive concurrent review of the medical record. Interactions with physicians, nursing staff, other patient caregivers, and coding staff is necessary to ensure accurate inpatient coding and legitimate DRG assignment for the level of service rendered to all patients.
Essential Functions and Responsibilities:
Initiates and performs admission and concurrent documentation review of selected inpatient records to clarify conditions / diagnoses and procedures where inadequate or conflicting documentation exist. Retrospective reviews may also be performed at the request of hospital administration and coding personnel.Demonstrates knowledge of MS-DRGs, documentation opportunities, and clinical documentation requirements. Serves as a resource for physicians to help link coding guidelines and medical terminology to improve accuracy of final code assignment.Communicates with the individual physician(s) or medical staff departments to facilitate complete and accurate documentation of the inpatient record to accurately reflect and report the patient’s severity of illness equating to intensity of service.Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.Works collaboratively with Health Information Management (HIM) department by concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment. Assists the HIM department in facilitation of the physician query process.Assists with management of reports from the software tracking tool.Other duties as assigned.Predictable and reliable attendance.