GENERAL SUMMARY:

The Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness and accuracy of medical record documentation. Provides direction in CMS Inpatient Prospective Payment System (IPPS) by obtaining appropriate clinical documentation through extensive interaction with physicians, nursing staff, other caregivers, and Health Information Management Coding Specialists to ensure the clinical documentation is complete and accurate to reflect the level of service rendered to patients.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Works with clinicians, including physicians, to facilitate appropriate clinical documentation in the medical record.

3. *Provides concurrent review of the clinical documentation in the medical record; reviews the medical record with a clinical lens to identify any missing or understated diagnoses.

4. *Queries the medical staff when necessary through written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.

5. *Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

6. *Reviews documentation or coding issues with Coding Specialists to assign a working DRG.

7. *Educates internal customers on clinical documentation opportunities, coding and reimbursement issues.

8. *Collaborates with physician leadership to design and implement tools to support medical record documentation.

9. *Examines and provides feedback on concurrent and retrospective physician queries.

10. Attends in-house education sessions to maintain knowledge of Clinical Coding Guidelines, Coding Compliance standards and CDI concepts.

11. Performs a thorough chart review to determine the appropriate principle diagnosis of the patient and to identify co-morbidities/complications. Documents these appropriately within the concurrent CDS worksheet to utilize critical thinking to analyze problems, identifies needs and priorities and implements effective work strategies.

12. Performs other related duties as assigned.

(Essential Job functions are marked with an asterisk “*”).

REQUIRED KNOWLEDGE, SKILLS AND WORKING CONDITIONS:

1. Knowledge of diagnostic testing, surgical procedures, disease process and care paths.

2. Knowledge of Inpatient Prospective Payment System (IPPS), Coding Regulations and documentation requirements.

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Knowledge of anatomy, physiology, pharmaceuticals, medical terminology, disease process and ICD-10-CM Coding.

5. Skill in coaching and educating peers and physicians.

6. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, ancillary departments and volunteers.

7. Ability to prioritize work demands and work with minimal supervision.

8. Ability to communicate effectively both verbally and in writing.

9. Ability to maintain confidentiality relevant to sensitive information and HIPPA guidelines.

10. Ability to meet high standards for work accuracy and productivity.

11. Ability to maintain flexibility and prioritizes daily responsibilities.

EDUCATION AND EXPERIENCE:

Must meet one of the following requirements:

1. Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of three (3) years recent clinical experience in an acute care setting required

2. Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or inpatient Coding Specialist. Certified Coding Specialist (CCS) certification is required upon hire or within twelve (12) months of hire date. Minimum of two (2) years recent inpatient coding experience in an acute care setting is preferred.

3. Applicants may have obtained a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) (or both) certificate, and will be considered for this position, having at least two (2) years’ experience doing this job.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.