5+ years of experience required
The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. This position facilitates and obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, patient care providers, and Health Information Management coding staff to ensure the clinical documentation reflects the level of service rendered to patients is complete. Additionally this position educates members of the patient care team on clinical documentation guidelines on a continuous basis.
- Participates in/initiates performance improvement activities, including team membership; utilizes "Plan for Change" process, including "FADE," for problem solving and performance improvement.
o Improves the overall quality and completeness of clinical documentation by performing admission/continued stay review for specific patient population using clinical documentation guidelines.
o Conducts follow up review at least 3-4 times per weeks of clinical documentation to ensure points clarified with the physician have been recorded in the patient's chart. Confers with RN documentation staff regarding cases. Has ongoing discussions with physicians regarding cases-has addendums completed in the appropriate format.
o Maintains a positive relationship between CDMP and the Medical Staff.
o Assists the department to maintain the hospital's financial stability –achieve SQP- CMI for Medicare and non-Medicare
o Participates in CDMP/Medical Records committee meetings to identify needs for clinical documentation
o Participates in efforts to monitor and improve CDMP process-FY09 imitative- add NYS DRGs to CDMP process-APR-DRG
o Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
o Reviews clinical issues with the coding staff to assign a working DRG.
o Maintains clinical knowledge through continuous learning.
o Develops and conducts ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, nursing and allied health professionals.
o Facilitates appropriate clinical documentation to ensure that the level of service and acuity of care are accurately reflected in the medical record.
o Participates in the evaluation process for employees, volunteers, students/interns and makes recommendations concerning performance improvement.
QUALIFICATIONS / REQUIREMENTS:
- Acts as a mentor/resource for new orientees.
- Delegate's tasks to support staff commensurate with their knowledge, skill and experience; guides and supervises staff to ensure quality performance.
- Demonstrates critical thinking during concurrent documentation review.
- Participates in aggregate data collection and analysis.
- Demonstrates required computer skills (Affinity; GUIDE, CDMP Trak)
- Ensures worksheets are constructed according to JATA standards. Data is entered into Trak accurately and in a timely manner
- Processes discharges by updating the Severity/Complexity of services worksheet to reflect any changes in status, procedures/treatment, and confers with physician to finalize diagnosis.
- Assists with the development of initiatives that support CDMP process.
- Participates in data collection for quality improvement.
Minimum of 10 years acute care clinical experience, preferably with management experience; previous CDI experience, preferred.
Registered Nurse, BSN; Masters preferred.
Licenses / Certifications:
Certified Clinical Documentation Specialist certification required after 1 year of employment
The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials.