Clinical Documentation Specialist II

Position Summary 

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes. 

• Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries. 
• Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.  
• Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.  
• Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined. 
• Performs ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities.  
• Supports the Coding Department through communicating with physicians regarding open queries; acts as liaison between coding and physicians.  
• Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.  
• Collaborates with the Physician Advisor in identifying patterns of physician documentation issues, 
• utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings 
• Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation. 
• Participates in orientation, precepting, and mentoring of new team members. 
• Other related job tasks or responsibilities as assigned 

• Special Skills 
  • Knowledge of care delivery documentation systems and related medical record documents. 
  • Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.  
  • Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff.  
  • Computer skills and familiarity with basic office equipment required.  
  • Ability to work independently in a time oriented environment.  
  • Self-directed, motivated, and possess a positive attitude. 
• Minimum Requirements 
  • Education: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine 
  • Experience: 2-5 years CDS experience 
  • Licensure/Certifications: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP 

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