Clinical Documentation Specialist

Role Overview

• Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines. Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record. The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators; then queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
• Performs a thorough chart review to determine the most appropriate principal diagnosis of the patient.
• Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet.
• Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses.
• Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care.
• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
• Maintains the ability to be flexible and prioritizes daily responsibilities.
• Uses strong and professional communication skills with providers to clarify information in the medical record. Uses appropriate and compliant querying tools (templates) to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or individually with physicians.
• Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Identifies areas of focus through report analysis.
• Experience with CDI for Peds, Neonatal, and OB.

Requirements

• Minimum: Associate's Degree Nursing
• Preferred: Bachelor’s Degree or higher in Nursing
• Preferred: Current RN License
• Minimum: Basic MS office skills; including Excel, Word, Outlook. Basic proficiency in computer applications.
• Preferred: EPIC, 3M 360, 3M eMD
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators. Up-to-date clinical knowledge.
• Ability to create and maintain strong relationships and confidently discuss clinical diagnoses. Skills in negotiation, conflict resolution, follow through and follow up. Ability to work independently in a time-oriented environment.
• The employee communicates effectively. Excellent and professional written and verbal communication skills. Ability to write concisely and effectively when communicating with providers.
• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Good organizational skills with attention to detail and accuracy. Maintains the ability to be flexible and prioritizes daily responsibilities.

Benefits

• Cottage Health is an Equal Opportunity Employer. Cottage Health applicants are considered solely based on their qualifications, without regard to race, color, ethnicity, religion, age, gender, transgender, gender expression and identity, national origin, ancestry, disability, sexual orientation, marital status, military status or any other classification protected by law. This policy applies to all aspects of the relationship between Cottage Health and an applicant or employee. Cottage Health is committed to upholding discrimination-free hiring practices. We strive to cultivate an environment where exceptional people bring diverse perspectives and find belonging, support and connection to their work.

Any Cottage Health applicants who require assistance or reasonable accommodations during the application process may request the need for accommodation with the Recruiter.