Clinical Documentation Improvement Specialist
Arkansas Children's Hospital - Little Rock, AR

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Position Summary
Ensures overall quality and completeness of clinical documentation. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to support appropriate reimbursement and ensure that clinical severity is captured for the level of service rendered to all patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates/trains all members of the patient care team on an ongoing basis.

Position Duties

Facilitates appropriate clinical documentation by ensuring the overall quality and completeness of clinical documentation by performing in-house patient medical record documentation assessments by following certain selection criteria and clinical documentation guidelines.
  • Reviews charts and completes clinical documentation improvement worksheet within 24 hours of admission.
  • Identifies the most appropriate principle diagnosis and CC’s to accurately reflect severity of illness in compliance with government regulations.
  • Confers with coding specialists concurrently to ensure appropriate working DRG and completeness of supporting documentation.
  • Confers with physicians face to face and/or via query to clarify documentation in the record, obtain needed documentation, present opportunities and educate regarding the significance of appropriate documentation needed to support the clinical severity of the patient.
  • Conducts follow-up reviews of clinical documentation with physicians queried to ensure points of clarification have been recorded in the patient’s chart and contacts physicians as needed
  • Processes discharges by updating clinical documentation improvement worksheet to reflect any changes.
  • Perform any other duties as assigned.

Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation; tracks responses and trends in compliance with the clinical documentation improvement program.
  • Effectively identifies documentation issues and follows up until improvement is seen.
  • Completes trends analyses and reports findings.
  • Advises co-workers on identified documentation issues and guidelines.
  • Participates in departmental quality assurance activities.
  • Follows processes regarding ongoing review and follow-up of documentation goals and issues to be addressed.
  • Maintains integrity of data collection.

Stays current with and conducts ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, nursing staff and allied health professionals.
  • Educates and trains all internal clinical customers on clinical documentation opportunities to better reflect the patient care provided.
  • Ensures ongoing education with the physician regarding documentation in the medical record.

Participates in continuing education
  • Attends and actively participates in all in-services and continuing education opportunities offered. Employees are encouraged to bring recommendations for education topics and/or opportunities for outside education sessions to their managers.

Position Qualifications

Education Requirements

Associate's degree or equivalent from two-year college program or technical school or nursing diploma Field of Study: Graduate from an accredited school of nursing or Graduate from an accredited school of Health Information Management

Bachelor's degree from four-year college or university Field of Study: Graduate from an accredited school of nursing or Graduate from an accredited school of Health Information Management

Experience Requirements

2 years total experience required • •
which includes 2 years of of Clinical Nursing or Health Information Management experience


2 years years of Coding Inpatient visits in an Acute Care Hospital experience

2 years Utilization Review experience

Certification/License/Registry Requirements

RN License (AR or Compact State) or Registered Health Information Administrator (RHIA) (Certification) • Candidate must possess at time of hire

National Coding Certification

Skill Requirements

Strong interpersonal, communication (verbal, non-verbal, and listening) skills.

Basic knowledge in use of computers and printers and/or ability to learn appropriate software application(s).

Ability to work independently with limited supervision

Ability to work with others in a team approach to coordinate work

Must be able to maintain confidentiality of sensitive information.

Ability to work under strict deadlines

Understanding of ICD-10-CM and ICD-10-PCS

Physical Requirements

Physical Activity - Stand

Physical Activity - Walk

Physical Activity - Sit

Physical Activity - Use hands to touch, handle, or feel

Physical Activity - Reach with hands and arms

Physical Activity - Climb or balance

Physical Activity - Stoop, kneel, crouch, crawl, twist, or bend

Physical Activity - Talk or hear

Physical Environment - Inside Office Environment / conditions

Lifting/Pushing/Pulling Weight - Up to 10 pounds

Noise Level - In general, the noise level for this position is considered to be:

Arkansas Children's Hospital - 22 months ago - save job
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As the only pediatric medical center in the state, Arkansas Children's Hospital (ACH) serves the youngest Razorbacks from birth to age...