Clinical Documentation Spec

Clinical Documentation Spec

JOB SUMMARY / PURPOSE

Provides analysis, information and education to assist physicians and / or staff in using terminology that improves and supports documentation of patient care. Performs concurrent review and analysis of the clinical facts documented in the medical records. Concurrently queries the medical staff and other members of the healthcare team to obtain accurate and complete chart documentation that appropriately supports the severity of the patient's illness. Plans and provides education to the healthcare team regarding documentation requirements, clarity and completeness.

DEPARTMENT DESCRIPTION

The Clinical Documentation Improvement Department is the fundamental, strategic part of Samaritan Health Services’ efforts to improve patient outcomes, enhance clinical documentation guidelines, ensure compliance and upgrade financial performance. The CDI program is a comprehensive, multi-disciplinary, hospital wide initiative promoting accurate, clear, concise, complete, and compliant documentation efforts. CDI professionals analyze data, formulate concurrent & retrospective physician queries, track CDI performance metrics, and successfully collaborate with other healthcare professionals. CDI professionals engage in a beneficial collaborative partnership with the Healthcare team to secure accurate clinical documentation in the medical record using compliant methodologies, which will result in appropriate code assignment, correct reimbursement, decreased claims denials & reduced RAC reviews.

EXPERIENCE / EDUCATION / QUALIFICATIONS

One (1) of the following required :

Current unencumbered Registered Nurse license in state of residence and five (5) years nursing experience in an inpatient acute care setting. BSN and experience in ICU-CCU preferred.

Current Registered Health Information Technician Certification (RHIT) with CCS and six (6) years inpatient coding experience.

Experience in the following required :

Clinical Documentation.

Inpatient Coding and Reimbursement.

Quality assurance chart review, coding, auditing and / or case management.

Acute care utilization review or discharge planning.

Experience or training in Excel, Word and EMR required.

Certified Clinical Documentation Specialist CDIS preferred.

KNOWLEDGE / SKILLS / ABILITIES

Knowledge of clinical documentation requirements, DRG assignment, clinical conditions / procedures, quality outcome standards and documentation requirements to meet those standards.

Communication : Effective written and verbal communication skills to perform group presentations, tactfully discuss issues, and listen to and understand complex information / situations. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities.

Computer Literacy : Proficiency in computer applications, including word processing, spreadsheets, databases, and information systems.

Confidentiality : Knowledge of State and Federal (HIPAA) laws pertaining to confidentiality of protected health information. Ability to comply with laws and maintain confidentiality of patient information.

Time Management : Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure.

PHYSICAL DEMANDS

Rarely

(1 - 10% of the time)

Occasionally

(11 - 33% of the time)

Frequently

(34 - 66% of the time)

Continually

(67 – 100% of the time)

CLIMB - STAIRS

LIFT (Floor to Waist : 0"-36") 40 - 60 Lbs

LIFT (Floor to Waist : 0"-36") 60 or more Lbs

SQUAT Static (hold >

30 sec)

KNEEL (on knees)

SIT

LIFT (Floor to Waist : 0"-36") 20 - 40 Lbs

CARRY 2-handed, 20 - 40 pounds

SQUAT Repetitive

ROTATE TRUNK Sitting

REACH - Upward

PUSH (20-40 pounds force)

PULL (20-40 pounds force)

STAND

WALK - LEVEL SURFACE

LIFT (Floor to Waist : 0"-36") 0 - 20 Lbs

LIFT (Knee to chest : 24"-54") 0 - 20 Lbs

LIFT (Waist to Eye : up to 54") 0 - 20 Lbs

LIFT (Overhead : 54" and above) 0 - 20 Lbs

CARRY 1-handed, 0 - 20 pounds

CARRY 2-handed, 0 - 20 pounds

BEND FORWARD at waist

ROTATE TRUNK Standing

REACH - Forward

MANUAL DEXTERITY Hands / wrists

FINGER DEXTERITY

PINCH Fingers

GRASP Hand / Fist

PUSH (0-20 pounds force)

PULL (0-20 pounds force)

None specified

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