The Clinical Documentation Specialist facilitates the accurate representation of the severity of illness/risk of mortality by improving the quality, completeness and accuracy of the physicians clinical documentation through extensive medical record review and query process. Through active engagement and interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and other members of the healthcare team.
Comprehends, incorporates, and demonstrates Anthelio Healthcare Solutions Mission, Vision, and Values in behaviors, practices, and decisions.
- Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.
- Conducts concurrent medical record reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes.
- Communicates with and educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
- Collaborates with coding staff to ensure complete documentation of discharge diagnoses/co-morbidities are a complete reflection of the patients clinical status and care. Resolves all discrepancies in a courteous manner.
- Develops and presents on-going documentation education for staff including case managers, coders, physicians, residents, nursing and allied health professionals.
- Gathers and interprets clinical documentation data; Identifies documentation concerns, discrepancies, or issues. Determines methods to ensure compliance in accordance with clinical documentation policies and procedures.
- Utilizes interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues.
- Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate clinical documentation requirements for both DRG reimbursement and pay for performance quality measures.
-Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment. Serves as a role model by demonstrating professional practice behaviors.
- Performs other duties as assigned by Leadership.
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Anthelio Healthcare Solutions Standards of Conduct, Code of Ethics, as well as, other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
-Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and at least five years of current acute hospital care experience (i.e. medical/surgical unit, intensive care).
-Current Registered Nurse License in the State of practice.
-Certified Clinical Documentation Specialist (CCDS) preferred.
-Certification will be required within 1 year and maintenance of required Continuing Education Units (CEU). -Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred.
-Inpatient coding experience desired.
-Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. ----Strong critical thinking skills and ability to integrate knowledge.
-Prioritization and organizational skills required.
-Ability to educate all members of the healthcare team related to clinical documentation.
-Demonstrated ability to use a standard desktop and windows based computer system, including a basic understanding of email, internet, and computer navigation.
-Ability to use other software as required to perform the essential functions on the job.
-Experience with Microsoft Office Word, Excel and PowerPoint software preferred.
-Comfortable operating independently in a collaborative, shared leadership environment.
- Possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Anthelio Healthcare Solutions.
- Complete a clinical exam and achieve an 80% passing score.
- Must be able to travel to various locations (20%) as required.
Physical and Mental Requirements and working conditions:
- Able to set and organize own work priorities, and adapt to change when needed.
-Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
- Ability to comply with Anthelio Healthcare Solutions policies and procedures.
- Able to spend majority of time utilizing a computer, monitor and keyboard.
- Able to perform some lifting and/or pushing/pulling up to 20 pounds.
- Able to work with interruptions and perform detailed tasks.
- Proficient on working on different projects simultaneously and coordinate work to meet deadlines.
- Skilled ability to concentrate and read for long periods of time.
- Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading.
- Must be able to sit for long periods of time.