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RN-CLINICAL DOCUMENT SPECIALIST, UR-CASE MGMT
The Clinical Documentation Specialist is responsible and accountable for the day-to-day implementation and success of the Clinical Documentation Improvement Program. Primary responsibilities through a concurrent review and evaluation of the medical record are facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality and complexity of care of the patient, including appropriate principal diagnosis/procedure and secondary diagnoses/procedures. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment and clinical conditions or procedures Educates all members of the patient care team regarding documentation guidelines which includes discussions...
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