Clinical Documentation Specialist - Clinical Documentation

Job Summary

The clinical documentation specialist works collaboratively with providers and coding staff to ensure that the documentation in the medical record accurately reflects the quality and level of care provided. The overall goal of the position is to improve clinical documentation for quality assurance and revenue compliance and integrity. 

Scope & Impact: Through clinical validation queries emphasizing a reduction in reported hospital-acquired conditions and increasing clinical evidence in support of certain ICD-10 guidelines, the CDI specialist is responsible for several initiatives including but not limited to: reimbursement methodologies, data stewardship and collection, quality measures, medical necessity, and denial prevention.

Physical Requirements

• The ability to perform the duties and responsibility of the position, with or without reasonable accommodations for disabilities. 


• The ability to consistently lift, push or pull loads of up to fifty (50) pounds. (Unless nursing 50)


• Sufficient strength, mobility and stamina to make frequent location and position changes, assist with patient care, and perform other physical activities of average difficulty.  


• Candidates whose disabilities make them unable to meet the requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodations.


• May be exposed to infectious or contagious disease.


• May have to handle emergency situations.


• May be subject to irregular hours.


• May be required to wear protective equipment such as eye protection, face protection, masks, sterile/nonsterile gloves, isolation gowns.


• May be exposed to toxic/caustic/chemicals/detergents.            


• Physical activities include continuous sitting, and occasional walking, standing, bending, squatting, climbing, kneeling and twisting.


• Activity Conditions (Occasionally, Frequently, Continuously):
  
  
  
  • Sitting- Continuously 
  
  
  • Walking- Frequently  
  
  
  • Standing- Frequently  
  
  
  • Bending-Frequently  
  
  
  • Squatting- Occasionally 
  
  
  • Climbing-Occasionally
  
  
  • Kneeling-Occasionally
  
  
  • Twisting-Occasionally
  
  

Visual and Hearing Requirements

• 
  

  Must be able to see with corrective eye wear.



• 
  

  Must be able to hear clearly with assistance. 

Working Conditions

Primarily Works in a well-lighted and air-conditioned environment with period of heavy workload and stress. This role may include working in less-than-ideal home conditions, which can include exposure to extreme temperatures and environments that may not meet typical cleanliness standards such as clutter, unkept surfaces, and homes with pets. Works in various conditions. 

Performance: Essential Functions

Decision Making: Ability to make decisions and takes appropriate action based on the information they have. Recognizes own limitations and consults with the supervisor, manager, or team member when appropriate.

Time Management: Works efficiently and manages duties to ensure that tasks are completed with accuracy and within the scheduled shift or reasonable amount of time.

Quality & Quantity: Demonstrates accurate, knowledge and skill to carry out job duties. Follows departmental work policies and procedures. Speed and consistency of output, and time utilization of job duties.

Computer Knowledge & Electronic Equipment Use: Demonstrates ability to consistently utilize electronic equipment and online computer programs to perform job duties, including electronic documentation, and order entry.

Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost charges and unnecessary equipment repair-replacement.

Confidentiality: Adheres to established policies on privacy and security requirements for compliance with the Health Insurance Portability and Accountability Act (HIPAA), as applicable by Shannon Policy.

Supervises the Following Positions

Positions: N/A

Performance: Position Specific Essential Functions

• Collecting patient information related to diagnosis and course of care by conducting daily chart reviews.

• Assessing documentation validity utilizing CDI analytic software and critical thinking skills

• Identifying and communicating query opportunities with providers (for needed documentation support, ambiguity, or conflict).

• Meeting productivity requirements by maintaining daily/weekly query rate.

• Communicating with coding, providers, and applicable team members on documentation improvement needs.

• Upholding the integrity of the hospital medical record by complying with organizational, legal, ethical, and regulatory requirements. 

• Providing superior customer service to customers and coworkers with professional conduct and respectful behavior. 

• Strong interpersonal skills that allow for effective communication with different levels of hospital personnel

• Solid verbal and written communication skills required. 

• Organization, prioritization, critical thinking, and attention to detail are needed. 

• Basic computer and office equipment knowledge; Electronic Medical Record training provided.

• Prior knowledge of medical and pharmacology terminology required.

• Performs other duties as assigned.

Qualifications

Education

• Required 

  • High School Diploma, GED, or equivalent 

  • Associate's degree in Nursing 

• Preferred

  • Bachelor's degree in Nursing or clinical related field 

  • Doctor of Medicine 

    • Required in lieu of a licensed Registered Nurse 

Experience:

• Preferred

  • One year of experience in Clinical Documentation improvement and/or clinical coding

  • Three years of experience in acute care, hospital setting, or case management 

Certification/Licensure:

• • Registered Nurse (RN), with authorization to practice in the State of Texas 

    • Unless a Medical Doctor 

• Preferred

  • RHIT/RHIA/CDIP/CCDS or clinical documentation certification