Job Description

Clinical Documentation Specialists provide concurrent review of the clinical documentation in the medical records. Provides education to physicians and mid-level providers to ensure accurate coding and appropriate reimbursement.

Department: Medical Records

Hours: Day Shift

Starting Salary: $63,564.80+, pay based on applicable experience.

*RN Required.

Responsibilities

Assessment – Collects pertinent data and information relative to the patient’s health or the situation. Recognizes normal and abnormal findings when gathering data., Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.

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Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality, Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings within the CDS tracking software, denoting all key information utilized in the tracking process, Coordination of Care – Plans and evaluates care in collaboration with appropriate disciplines., Demonstrated creativity and enthusiasm while pursuing the goals of the department and the organization, Demonstrates an understanding of the importance of and makes an effort to capture all appropriate secondary diagnoses for quality ratings/profiling purposes., Diagnosis – Analyzes assessment data to determine actual or potential diagnosis, problems, issues., Evaluation – Evaluates progress toward attainment of goals and outcomes.

Reports data and outcomes to others as appropriate., Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needs documentation. , Implementation – Implements care or work plan in alignment with the plan and approved safety, infection control,and department/organization standards., Knowledge – In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Maintains the ability to be flexible, and prioritizes daily responsibilities, Outcomes Identification – Identifies expected outcomes for a plan individualized to the patient or situations., Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately within the concurrent Clinical Documentation Specialist (CDS) tracking software., Planning – Develops a plan that prescribes strategies to attain expected, measurable outcomes.

Queries the medical staff and other care givers as necessary via written/verbal communication., Relationships – Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Reviews the progress of the concurrent documentation review program, through interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Able to identify areas of focus through report analysis. , Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Provides information and informal in-services as necessary to physicians and ancillary staff., Teaching – Employs teaching strategies to promote health and a safe environment.

Clinical Documentation Specialist (Registered Nurse) – Remote IL id-1274

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