Clinical Document Specialist RN, Full Time

Unity Health • Searcy, AR

6d

About The Position

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation according to clinical documentation guidelines, established criteria, and policies and procedures.

Utilizes knowledge of functional health patterns, physiology, pathophysiology, and psycho sociology in documentation efforts and other projects related to Outcomes Management.

Facilitates appropriate clinical documentation to ensure that the severity of illness and level of services provided are accurately reflected and documented in the medical record.
Improves overall quality and completeness of clinical documentation to ensure an appropriate DRG is assigned to each patient with a DRG based payor.

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

Demonstrates ability to understand, apply and integrate key clinical care, quality, and documentation components ( e.g., DRG’s, diagnoses, clinical procedures, coding, intensity of service, referral policies and procedures, clinical pathways, case mix index).

Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association ( AHIMA ).

Establishes open and active communication with all hospital associates and physicians regarding clinical documentation.
Serves as a resource for clinical documentation and provides support to associates regarding complex patient issues and the impact on clinical documentation needs; provides consultative services to medical and nursing staff related to documentation and core clinical indicators.

Able to communicate verbally and in written format with the Medical Staff, review organizations, administration and others as required.

Consistently updates patient’s DRG worksheet to reflect any changes in status, procedures / treatments, and confers with physicians to finalize diagnoses.
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient’s chart.
Tracks responses to documentation improvement program and trends completion of DRG query worksheets.

Reviews clinical issues with coding staff to assign a working DRG.
Assists with education of coders, physicians, and all members of the health care team on clinical documentation opportunities and reimbursement issues.

Contributes to financial integrity of the Department through identification, implementation, and evaluation of cost-effective practices.
Assesses learning needs and assists in the evaluation of systems and processes to improve patient outcomes.

Demonstrates initiative, ability, and judgment in analysis and management of data.
Able to adequately interpret financial reports, audits, etc.
Evaluates and integrates appropriate research findings into clinical documentation practices as appropriate.

Demonstrates ability to work under pressure and in conditions of frequent interruptions.

Willingly accepts additional responsibilities while managing current and competing priorities.
Performs other duties as assigned.

Understands and demonstrates behaviors consistent with the mission of the organization while contributing to the overall success of the strategic plan and providing excellent customer service.

Requirements

• Current Arkansas licensure as a registered nurse
• Must have either AHIMA (American Health Information Management Association), RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) Certification
• Knowledge of clinical documentation guidelines, ICD-9-CM and CPT-4 coding conventions, DRG and APC assignment, policies and procedures, and third party payer requirements
• Computer and software competencies inherent to the position, including Coding and DRG assignment software, intranet, email, hospital computer system, Excel
• Analytical skills, knowledge of related to the clinical documentation process, indepth coding and clinical knowledge demonstrated in order to gather and interpret clinical data to identify discrepancies, problems or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures

Nice To Haves

• Bachelor of Science (BSN) preferred
• Coding Credentials (through AHIMA) a plus
• Previous clinical documentation experience a plus

Responsibilities

• Improving the overall quality and completeness of clinical documentation
• Facilitating appropriate clinical documentation
• Ensuring an appropriate DRG is assigned to each patient with a DRG based payor
• Establishing open and active communication with all hospital associates and physicians regarding clinical documentation
• Serving as a resource for clinical documentation
• Providing support to associates regarding complex patient issues and the impact on clinical documentation needs
• Providing consultative services to medical and nursing staff related to documentation and core clinical indicators
• Communicating verbally and in written format with the Medical Staff, review organizations, administration and others as required
• Updating patient’s DRG worksheet to reflect any changes in status, procedures / treatments
• Conferring with physicians to finalize diagnoses
• Conducting follow-up reviews of clinical documentation
• Tracking responses to documentation improvement program and trends completion of DRG query worksheets
• Reviewing clinical issues with coding staff to assign a working DRG
• Assisting with education of coders, physicians, and all members of the health care team on clinical documentation opportunities and reimbursement issues
• Contributing to financial integrity of the Department through identification, implementation, and evaluation of cost-effective practices
• Assessing learning needs and assists in the evaluation of systems and processes to improve patient outcomes
• Demonstrates initiative, ability, and judgment in analysis and management of data
• Interpreting financial reports, audits, etc
• Evaluating and integrating appropriate research findings into clinical documentation practices as appropriate
• Accepting additional responsibilities while managing current and competing priorities
• Performing other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level