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Clinical Documentation Specialist - Obstetrics, Newborn & Pediatrics

VIRTUAL-GA • Atlanta, Georgia • Shift • Full Time • JR-18495

Facility: VIRTUAL-GA

Job Summary:

The Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.

Core Responsibilities and Essential Functions:

Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff. a) Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation. b) Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart. c) Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned. d) Submits documentation clarification queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population. e) Ensures queries are compliant, grammatically correct, concise, and free of typographical errors. f)Provides appropriate follow-up on all queries. g) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist. h) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated. i)Maintains required daily/weekly/monthly metrics. Meets productivity standards. j)Participates in required departmental meetings, conference calls and presentations. k) Adheres to departmental Policies and Procedures. l)Submits ideas to improve workflow and increase productivity/efficiency of his/her team to the CDI Leadership Team and performs any other duties as assigned. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintains knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis. a) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. b) Participates in assuring hospital compliance with Federal and State regulatory requirements. c) Educates members of the patient care team, including medical staff, on documentation guidelines on an on-going basis Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital, and regulatory outcomes. a) Reviews data and trends to identify additional areas of opportunity. b) Provides input to core measure and other quality data initiatives regarding areas for investigation and education. c) Identifies and participates in opportunities to improve documentation, Epic, and quality of care initiatives.

Required Minimum Education:

  • Associates Nursing or Bachelors Health Science or Bachelors Nursing or Doctorate Medicine

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

Clinical Background Candidates:

It is expected that all RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire required.

It is expected that all MD/IMG candidates have completed their degree from an accredited medical school. Upon Hire required.

Non-Clinical Background Candidates:
It is expected that all non-clinical (coding) background candidates have at least one of following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or Registered Health Information Technician (RHIT) from AHIMA Upon Hire required.

  • Cert Document Improvement Prac-Preferred or Cert Clin Document Specialist-Preferred

Required Minimum Experience:

Minimum 1 year of working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and
Minimum 5 years of healthcare experience Required and
Epic and Solventum/3M 360 Encompass experience is preferred Preferred and
Prior experience of working as a CDI/Coding auditor is preferred Preferred and
Prior experience of working in inpatient case management or utilization review is preferred Preferred and

Required Minimum Skills:

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
Epic and Solventum/3M 360 Encompass experience is preferred
Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives
Excellent communication skills, employing tact and effectiveness
Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members
Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions
Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions
Drives optimal use of the CDI technology tool and reporting capabilities

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