Clinical Documentation Specialist

The Clinical Documentation Specialist coordinates and maintains the elements and requirements of the Clinical Documentation Improvement Program, including staff and physician education, to ensure the highest quality of documentation in support of compliance and accurate representation of the care provided to the patient

Essential Job Functions

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.
• Meet CDI program objectives, goals, and balance scorecard metrics.
• Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Ensure effective communications with key stakeholders.
• Analyzes data, creates reports to meet desired outcomes.
• Identifies trends and opportunities for improvement in clinical documentation.
• Meets program quality and productivity guidelines and standards.
• Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.
• Work effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

Key Success Indicators/Attributes

• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate mentoring and interpersonal skills.
• Demonstrate excellent presentation, verbal, and written communication skills.
• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
• Maintains courteous and professional working relationships with employees at all levels of the organization.
• Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.
• Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required
• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones .

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• Experience: Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum Experience: Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Preferred Experience: Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Education: Bachelor’s degree, with a healthcare related credential

Additional Eligibility Qualifications

None required

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. Employee may perform other duties as assigned.

Must Have Skills/Experience: Proven experience with ICD-10-CM/PCS coding, DRG assignment, and query processes. Familiarity with CMS Inpatient Prospective Payment System (IPPS), risk adjustment methodologies, and value-based purchasing programs. Windows, Excel experience.

EHR: MedHost, Iodine CDI software

• Supervisor: Belinda Newsted & Marcia Floyd, CDI Manager Central Division

Qualifications

Education

• Required: RN, BSN, or foreign medical graduate (FMG) with strong clinical background; OR RHIA/RHIT/CCS credentialed HIM professional with significant inpatient coding experience.
• Preferred: Bachelor’s or Master’s degree in Nursing, HIM, or related healthcare field.

Required Certifications – One or more of the following

• Certified Clinical Documentation Specialist (CCDS) – ACDIS
• Certified Documentation Improvement Practitioner (CDIP) – AHIMA
• Certified Coding Specialist (CCS) – AHIMA

• Years of Experience: Minimum of 3–5 years in clinical practice preferably CCU/ ICU , inpatient coding, or CDI role.