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Job Summary:
The Remote Clinical Documentation Specialist (CDS) demonstrates strong clinical knowledge and understanding of coding/DRG requirements to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The CDS works collaboratively with physicians, other healthcare professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.
Core Responsibilities and Essential Functions:
Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, mid-level providers, case management team, nursing team, other patient caregivers, and HIM coding team.
- Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation.
- Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
- Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
- Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
- Ensure queries are compliant, grammatically correct, concise and free of typographical errors.
- Provides appropriate follow up on all queries.
- Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist.
- Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated.
- Maintains required daily/weekly/monthly metrics. Meets productivity standards.
- Participates in required onsite meetings, conference calls and Skype presentations.
- Adheres to departmental Policies and Procedures.
- Participates in assuring hospital compliance with Federal and State regulatory requirements.
- Submit ideas to improve work flow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintain knowledge base of current medical terminology, procedures, medications and diseases to provide accurate patient record analysis.
- Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes.
- Reviews data and trends to identify additional areas of opportunity.
- Provides input to core measure and other quality data initiatives regarding areas for investigation and education (PSI’s and HAC’s).
- Identify and participate in opportunities to improve documentation, EPIC, and quality of care initiatives.
Required Minimum Education:
Bachelor's Degree in nursing or other health-related field Preferred
Required Minimum License(s) and Certification(s):
Cert Clin Document Specialist 1.00 Required
Cert Coding Spec 1.00 Required
Cert Document Improvement Prac 1.00 Required
Reg Nurse (Single State) 1.00 Required
RN - Multi-state Compact 1.00 Required
Additional Licenses and Certifications:
Required Minimum Experience:
Minimum 5 years of healthcare experience Preferred and
Strong medical surgical and/or critical care background Preferred and
Minimum 2 years clinical documentation improvement experience Preferred and
Experience with care coordination/utilization management, coding/DRG, billing, auditing and various healthcare payers Preferred and
Clinician preferred and/or CDIP/CCDS credential Preferred and
It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Required and
EPIC Electronic Medical Record and CDI Software experience Preferred
Required Minimum Skills:
Self-directed with good written communication skills necessary to effectively communicate with physicians and other healthcare providers.
Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected.
Chart review experience required.
Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred.
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