Job Description

Clinical Documentation Specialist SR 

Position Highlights:

• The Clinical Documentation Specialist Senior is a responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. 
• The Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with on-site meetings, zoom meetings, telephonic discussions, rounding and email. This position will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate. 
• Additionally, the Clinical Documentation Specialist Senior is expected to function as a subject matter expert on the team and assist less experience team members in understanding and following operational policies. This role is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

Responsibilities: 

• Reviews medical records for quality, completeness, and accuracy of documentation. Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation. Must meet and maintain the quality and productivity measures established per polices.
• Delivers ongoing education to providers through collaboration and communication via on-site meetings, zoom meetings, telephonic discussions, rounding, and email. Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians.
• Identify and share documentation improvement opportunities with providers to capture the patient's accurate severity of illness and risk of mortality, comorbid conditions, and all other condition categories. 
• Develop clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non specified documentation. Utilizes software system and the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
• Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with other committees as directed
• The Senior is expected to function as a subject matter expert on the team and assist less experience team members on following operational policies. It is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

Credentials and Experience:

• Associate’s Degree – field of study: Nursing, HIM or another Healthcare related field.
• A minimum six (6) years acute care clinical documentation experience.
• ICD-10-CM and ICD-10-PCS coding and query process knowledge.
• Ability to recognize opportunities for documentation improvement, and hold collaborative discussions with providers to address the opportunities in documentation. 
• Proficient in computer skills including: MS Office, Optum 360 eCAC, Cerner HER.

Certifications: 

• (CCDS) Certified Clinical Documentation Specialists from ACDIS.
• (CDIP) Certified Documentation Integrity Practitioner from AHIMA.
• (CDEI) Certified Documentation Expert Inpatient from AAPC.
• Registered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement.

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