Clinical Documentation Specialist- Full Time

• Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.

• 1)Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• 2)Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• 3)Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• 4)Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• 5)Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• 6)Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• 7)Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• 8)Gather and analyze information pertinent to documentation findings and outcomes
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.

• 1)Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.
• 2)Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation
• 3)Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• 4)Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• 5)Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff
• 6)Maintains knowledge of current standards of care via literature review and participation in educational offerings
• 7)Research literature to identify new methods development and overall documentation enhancement
• 8)Complete required contact hours based on FTE status, within time frame
• Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.

• 1)Completes documentation on reviewed cases in the database.
• 2)Completes the DRG and query indicators for each reviewed case, as appropriate.
• 3)Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.
• 4)Identify patterns, trends variances and opportunities to improve documentation review and process
• 5)Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.
• Demonstrate positive and effective interpersonal relations dealing with all members of the team (i.e. co-workers, physicians, leadership, etc.).

• 1)Maintains a positive attitude about assignments and team members
• 2)Promotes professional/personal growth of co-workers by sharing knowledge and resources.
• 3)Manages stress and personal feelings without a negative impact on the team
• 4)Communicates in a positive and productive manner.
• 5)Demonstrates flexibility with changing workload/assignments.

• Nurse, Registered (RN)

• Graduate from an accredited school of nursing BSN 5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience) Clinical documentation improvement experience preferred

• Ability to prioritize work Excellent communication skills Good problem solving skills Critical thinking skills Basic Computer skills Effective problem-solver with good interpersonal communication skills, verbal and written Effective observation, analytical, and critical thinking skills
• Current nursing license in the State of Illinois. Certification in clinical documentation improvement preferred.

• Ability to work in changing environment Ability to prioritize independently and respond to multiple simultaneous requests Ability to work under stressful conditions and in difficult situations May be exposed to hazardous materials and life threatening diseases This position needs to recognize needs and behaviors of specific age groups of patients treated. Extensive knowledge and experience of ICD-10 coding classification system and DRGs
• none

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