Clinical Documentation Specialist - Clinical
Conducts clinically-based concurrent and retrospective review of inpatient medical records to evaluate whether the clinical documentation is representative of the severity of illness of the patient andrisk of mortality relative to the quality of care outcomes and reimbursement compliance for the acute care services provided.
Duties include focused APR-DRG studies, quality reviews, and highrisk retrospective reviews. Collaborates extensively with physicians,nurse practitioners, physician assistants, nursing staff and other ancillary caregivers and health information management coding staff, to improve the quality and completeness of documentation of care
. Evaluates hospitaladmission criteria and conduct concurrent review of initial,regular, and extended stay reviews on a majority ofadmissions. Serves as an expert resource forRN case managers and care providers who assign the correct patient status and level of care, andsupport the medical necessity of services. Conducts new hire and ongoing education of medical staff, residents,nursepractitioners and physician assistants regarding high-quality clinical documentation guidelines and practices.
Participates in performance improvement activities such as Maintenance of Certification (MOC) initiatives. Attends regular forums such as morning and afternoon rounds, and assists in the presentation, analysis and trending of statistical data for specific patient populations. Writes clinical appeal responses for APR-DRG denials.
Masters Degree in Public Health or Health Administration required. Minimum 12 monthsexperience in same or similar position required. Certified Coding Specialist (CCS) certification required. In lieu of the above listed Masters Degree and work experience, a suitable and acceptable substitute is a Bachelors Degree in Nursing or Medicine, or the foreign equivalent and 5 years of progressive work experience in the same or similar position.