Clinical Documentation Specialist
Franciscan St. Elizabeth Health - Central, IN

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Position summaryThis position is responsible for improving the overall quality and completeness of clinical documentation. This individual facilitates modifications to clinical documentation through extensive concurrent interaction with physicians and coding staff to ensure that the appropriate reimbursement and clinical severity is captured for the level of service rendered. The role supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.Essential ResponsibilitiesProvide daily clinical evaluation of the medical record documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures Communicate with physicians to ensure accurate and complete documentation is in the medical record. Communication is face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. Utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes. Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG. Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital's designated clinical documentation system. Gather and analyze information pertinent to documentation findings and outcomes Contribute to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends Identify patterns, trends variances and opportunities to improve documentation review and process Research literature to identify new methods development and overall documentation enhancement Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information Active participation on departmental and hospital committees and assigned Task Force groups Maintain interaction with appropriate resources that support growth and education of the CDI Team Maintain credentials/licensure/certification Knowledge, Skills AbilitiesA minimum of 10 years acute care experience with at least 2 years recent inpatient experience Proficiency in organization and planning Working knowledge of quality improvement theory and practice Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice Knowledge of federal, state and private payer regulations Experience working with teams and on projects. Excellent interpersonal, organizational, presentation, verbal and written communication abilities. Ability to effectively communicate, both orally and in written form, with people at all levels of the organization. Proficient computer and technical skills necessary in order to perform the tasks required, including advanced knowledge of information systems, databases, and spreadsheet applications Ability to work collaboratively with diverse groups. Ability to deal with conflicting interests and to resolve situations effectively. EducationRN/BSN preferred. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting Licensure/Certification: Current nursing state license from the state the job is geographically located; clinical documentation credential is desirable. Case Management, Coding, or experience in a related field preferred.

Keywords: Clinical Documentation Specialist