The Clinical Documentation Specialist conducts concurrent reviews based on specific criteria of opportunity to improve medical documentation practices. This review includes new admissions to the facility as well as re-reviews every two to three days until the patients are discharged. Identifies opportunities to justify the intensity of service and of illness in the patients treated and shares this information interdisciplinary approach with physicians, clinical staff and coding staff with the goal of obtaining documentation excellence supporting the care provided to the patient. Understands ICD – 9 (10) and CPT codes as needed. The CDI Specialist will proactively monitor DRG assignment to ensure documentation supports the DRG based on the diagnosis, care, and treatment being provided to the patient. Develops action plans to improve documentation in the open record as identified through the concurrent review process. Provides education to physicians and other clinical providers to ensure their understanding of the query process, ICD 9 (10), and the desired outcome of documentation our excellence for severity of illness and intensity of care.
Major Roles and Objectives:
*Ability to learn/develop the skills necessary to perform CDS
*Accurate and timely record review
*Recognize opportunities for documentation improvement
*Effective and appropriate communication with physicians
*Timely follow up
*Communicates with HIM staff
*Accurate input of data into CDS system
Graduation from a program of nursing or graduate of Health Information Management.
Skills Required –
*Organizational, writing and interpersonal skills
*Dependable and self directed
*Critical thinking and problem solving
*Minimum of three years hospital experience preferably in nursing or other clinical area, coding in an acute care facility required.
*Knowledge of ICD – 9 (10)
*Basic computer skills
Work Environment and Hazards:
Administration, office setting (attached)
Special Physical Demands:
Must meet requirements of the ADA (attached)
Work Contact Group:
Patients and family members, visitors, co-workers, supervisors, interdepartmental workers and physicians.