Job Description

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.

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.

Bryan Health