Clinical Documentation Specialist

Job Description : JOB DESCRIPTION

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions.

Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE : Clinical Documentation Specialist RN

JOB OVERVIEW : The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record.

This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff.

Active participation in team meetings and education of staff in the documentation improvement process is a key role.

DEPARTMENT : Health Information Management

HOURS OFWORK : Days Monday - Friday.

RESPONSIBLE TO : Manager, Clinical Documentation Improvement

PREREQUISITES :

Current unrestricted WA State Registered Nurse license, required.

Bachelor's degree in Nursing, preferred.

Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review

Pass a pre-hire Clinical Exam with a minimum score of 70%

Effective communication with Providers

QUALIFICATIONS :

Knowledge of hospital clinical practice standards for physicians and other health care providers.

Knowledge of ancillary service departments, quality control and safety standards.

Critical thinking, problem solving and deductive reasoning skills.

Familiarity with health care audit and research design.

Knowledge of Pathophysiology and Disease process.

Functional knowledge of DRG coding systems.

Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.

Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.

Meet productivity guidelines.

Ability to learn / develop the skills necessary to perform and meet goal standards

Organizational, analytical, writing, and interpersonal skills

Dependable, self-directed, and pleasant

Critical thinking, problem solving and deductive reasoning skills

Knowledge of Pathophysiology and Disease Process

Basic Computer skills - familiarity with Windows based software programs

Knowledge of regulatory environment

Understand and support documentation strategies (upon completion of training)

Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)

UNIQUE PHYSICAL / MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS :

See Generic Job Description for Administrative Partner.

PERFORMANCE RESPONSIBILITIES :

A.Generic Job Functions : See Generic Job Description for Administrative Partner.

B.Essential Responsibilities and Competencies

Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.

Accurate and timely record review.

Recognize opportunities for documentation improvement.

Initiates severity worksheet for inpatients.

Formulate clinically credible documentation clarifications.

Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.

Effective and appropriate communication with physicians.

Timely follow up on all cases and resolution of those with clinical documentation clarifications.

Communicates with HIM staff and resolves discrepancies.

Accurate input of data for reconciliation of case.

Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.

Identify any barriers to completion of documentation goals with appropriate interventions.

Review of regulations and coding guidelines through seminars, meetings, and materials.

In cooperation with the director of PFS / HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.

Maintains confidentiality of all accessible patient financial or medical records information.

Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.

Other duties as assigned to facilitate accurate, timely patient account management.

Date Created : 5 / 18, updated 7 / 22

Grade : NC11

FLSA : E

Cost Center : 8490

Job Qualifications : PREREQUISITES :

PREREQUISITES :

Current unrestricted WA State Registered Nurse license, required.

Bachelor's degree in Nursing, preferred.

Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review

Pass a pre-hire Clinical Exam with a minimum score of 70%

Effective communication with Providers

QUALIFICATIONS :

Knowledge of hospital clinical practice standards for physicians and other health care providers.

Knowledge of ancillary service departments, quality control and safety standards.

Critical thinking, problem solving and deductive reasoning skills.

Familiarity with health care audit and research design.

Knowledge of Pathophysiology and Disease process.

Functional knowledge of DRG coding systems.

Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.

Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.

Meet productivity guidelines.

Ability to learn / develop the skills necessary to perform and meet goal standards

Organizational, analytical, writing, and interpersonal skills

Dependable, self-directed, and pleasant

Critical thinking, problem solving and deductive reasoning skills

Knowledge of Pathophysiology and Disease Process

Basic Computer skills - familiarity with Windows based software programs

Knowledge of regulatory environment

Understand and support documentation strategies (upon completion of training)

Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)