Clinical Documentation Specialist - CDS
St. Rose Hospital - Hayward, CA

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The CDS is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation reviews for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting the findings.

Reviews inpatient medical records for identified payor populations (i.e., Medicare, etc.) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.

Ensures that clinical documentation reflects the level of service rendered to patients is complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services

Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and health information management staff.
Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 24 hours of admission, on the working days.

Manages the concurrent medical record review for clinical documentation improvement throughout the hospital. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical record.

Regularly participates in scheduled case management and hospitalist meetings and actively exchanges information pertaining to clinical documentation, plan of care affecting coding and reimbursement.

Maintains up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases.

Assists in the development of diagnosis/DRG specific queries to aid physicians with proper and precise documentation

Facilitates the appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient’s past medical history of conditions is appropriately documented.

Effectively utilizes documentation improvement communication tools.

Proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, coding and audit tracking.

Utilizes the encoder software to determine the working DRG and communicates daily with the HIM coding staff.

Resolves inconsistent, conflicting and/or ambiguous documentation through the physician query process.
Follows up with the physicians to get resolution of all queries prior to patient’s discharge.
Takes responsibility and assists coders in follow-up on queries and clarifications to physicians done retrospectively post patient discharge.

Maintains good rapport and cooperative relationships with medical staff, nursing staff, coding staff and hospital management. Approaches conflict in a constructive manner. Helps identify problems, offer solutions and participate in resolution.

Performs audits on the encoder software in order to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process

Works with health information management coding staff, physicians and financial services with regards to payment denials, medical necessity and documentation issues. Instructs staff on proper documentation in the medical record.

Reviews audit inpatient claims with medical necessity denials looking for patterns by service or by the ordering physician. Follow-up in improving clinical documentation to reduce such denials.
Maintains detailed Case Mix Index (CMI) reports for performance evaluation of CDI process.

Maintains DRG assignment mismatch report of differences in DRG assignment by CDS and coders and provides feed back to supervising the Manager or Director for performance evaluation of CDI process.

Fosters respect for privacy by maintaining confidentiality in all phases of the work
Has knowledge of and performs the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (QIO), Centers for Medicare and Medicaid Services (CMS).

On an ongoing basis educates all members of the patient care team on documentation guidelines. Devices educational materials to inform medical staff and nursing staff regarding to update on the clinical documentation requirements.
Actively participates and assists Performance Improvement Department in improving clinical documentation for compliance in quality of care measures (esp. Medicare CORE Measures) for specific charts

Performs other job related duties as assigned by the Director, Health Information Services.

Medical Graduate or Physician Assistant or Registered Nurse (with current valid license)

AHIMA certification as Certified Coding Specialist (CCS) is required.

Certified Clinical Documentation Specialist (CCDS)

*Proof of required License(s) and/or Certification(s) due at time of hire.

Medical Graduate or Physician Assistant with one year of clinical experience in acute care setting, or
Registered Nurse (with current valid license) with minimum of 3 years of clinical experience in an acute care setting

**Proof of required educational level(s) due at time of hire.

Prior case management experience is desirable


Working knowledge of Medicare reimbursement system and coding structures required.

Knowledge of care delivery documentation systems and related medical record documents.

Knowledge of age-specific needs and the elements of disease processes and related procedures.

Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.

Excellent written and verbal communication skills. Excellent critical thinking skills.

Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

Working knowledge of inpatient admission criteria.

Ability to work independently in a time-oriented environment.

Computer literacy and familiarity with the operation of basic office equipment

Assertive personality traits to facilitate ongoing physician communication.

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