Specialist, Clinical Document

THIS IS A REMOTE POSITION

TRINITY HEALTH

JOB DESCRIPTION

DATE ISSUED : October

DATE REVISED : November DEPARTMENT : Health Information Management, Revenue Excellence

JOB CODE : T JOB TITLE : Clinical Documentation Specialist

GRADE : 13

REPORTS TO : Regional Manager of CDI

FLSA : Exempt

APPROVED BY : VP HIM Coding

POSITION PURPOSE

Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.

Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.

Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.

Participates in the development and delivery of education for providers and members of the healthcare team.

ESSENTIAL FUNCTIONS

1. Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.

2. Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.

Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.

Serves as a resource for appropriate clinical documentation.

3. Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.

Identifies learning opportunities for healthcare providers.

4. Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.

5. Formulates compliant clarifications / queries following Trinity Health’s documentation integrity procedures.

6. Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification / query requests and educational opportunities.

7. Codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).

8. Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.

Resolves all discrepancies in a courteous manner.

9. Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.

10. Leverages the functions of 3M / for entering data related to CDI efficiencies and effectiveness.

11. Performs other duties as assigned by leadership.

12. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

MINIMUM QUALIFICATIONS

1. Must possess an Associate / Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP / APN) or Physician Assistant.

In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.

2. Preferred certification or licensure includes :

a. Current Registered Nurse License,

b. Registered Health Information Administrator (RHIA),

c. Registered Health Information Technician (RHIT),

d. Certified Coding Specialist (CCS),

e. Certified Clinical Documentation Specialist (CCDS)

f. Certified Documentation Improvement Professional (CDIP).

3. Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner / advanced practice nurse (NP / APN), or as an inpatient coder preferred.

4. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge.

Prioritization and organizational skills required. Effective presentation / facilitation skills to accomplish educational goals for all members of the healthcare team.

5. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation.

Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred.

6. Data entry skills and typing skills at minimum 30 wpm.

7. Must be comfortable operating independently and in a collaborative environment.

8. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

1. Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks / projects in an environment that may be stressful with individuals having diverse personalities and work styles.

2. Must possess the ability to comply with Trinity Health policies and procedures.

3. Must be able to spend majority of work time utilizing a computer, monitor and keyboard.

4. Must be able to work with interruptions and perform detailed tasks.

5. Ability to concentrate and read for long periods of time.

6. Ability to work in an onsite and virtual environment.

7. Must possess a valid driver’s license and be able to travel to the various Trinity Health sites (10%) as needed.

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification.

They are not to be construed as an exhaustive list of duties so assigned.