Clinical Documentation Specialist - Remote

Employment Type:
Full time
Shift:
Day Shift
Description:
Reviews Inpatient medical records for identified payer populations as directed, on admission and throughout hospitalization; utilizes clinical expertise to facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation and identify potential gaps in physician documentation.
Facilitates modifications to clinical documentation through extensive interaction with physicians in addition to working closely with nursing staff, and other patient caregivers to achieve appropriate clinical documentation to support the acuity of care rendered. Assists with development and delivery of education for members of the patient care team on documentation guidelines, coding, and reimbursement issues on an ongoing basis.
Essential Functions And Responsibilities

• Evaluates and integrates appropriate research findings into clinical documentation practices as appropriate.
• Applies basic knowledge of standards of coding to ongoing evaluation of medical record documentation and demonstrates clinical knowledge to understand, apply and integrate key clinical care, quality, and documentation components (e.g., DRG’s, diagnosis, clinical procedures, coding, intensity of service, referral policies and procedures, clinical pathway, case mix index).
• 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 queries.
• Reviews final DRG assignment to confirm a final working DRG and discusses clinical issues with coding staff to resolve any discrepancy between CDS and Coder
• Assists the Coding Manager with the education of all members of the health team on clinical documentation opportunities, coding and reimbursement issues.
• Formulates credible queries to improve clinical documentation of principal diagnosis, co-morbidities, and present on admission status is accurate in the record to ensure an appropriate DRG is assigned to each patient with a DRG based payor.
• Contributes to financial integrity of the department through identification, implementation and evaluation of cost-effective practices.
• 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.
• Utilizes 3M CAC/CDIS software to perform CDI function.
• Facilitates the acquisition and application of clinical, theoretical and financial knowledge and decision-making skills of department staff, physicians, and other health care provides.
• Establishes collaborative practice and maintains open communication with other nursing personnel, physicians and health care professionals regarding clinical documentation. Updates 3M CAC/CDIS to reflect any changes in status, procedures/treatments, and confers with physicians to finalize diagnoses.
• Demonstrates continuing expertise in data management and analysis. Able to interpret financial reports, audits, etc.
• Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
• Facilitates appropriate clinical documentation, to improve overall quality, completeness, and compliance of clinical documentation that will ensure that the severity of illness and intensity of services provided are accurately reflected in the medical record.

Required Education, Experience And Certification/Licensure
Education:

• Masters of Science, Nursing, or Health Information preferred.
• Bachelor of Science, Nursing (BSN) or Bachelor of Science in Health Information Management.

Credentials/Licensure:

• Current Registered Nurse License or Registered Health Information Administrator (RHIA).

Related Experience:

• 5+ years of clinical experience as an RN; adult inpatient med-surg or critical care. Basic knowledge of clinical documentation guidelines, policies and procedures and knowledge of DRG Coding required.
• 2+ years of clinical documentation experience is required.

Other Knowledge, Skills and Abilities:

• Ability to educate all members of care team related to clinical documentation.
• Excellent communication, interpersonal, collaboration and customer relations skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Ability to analyze data for patterns and trends.
• Prioritization and organizational skills required.

Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
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