Clinical Documentation Spclst

2197 Clinical Documentation Specialist STRHS-Lawrenceburg Job Description 10.11.2022
Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Reports to:

FLSA: Exempt

Grade:

EEO: □ 01 Officials and Managers □ 02 Professionals □ 03 Technicians □ 04 Sales Workers X 05 Administrative Support Workers □ 06 Craft Workers □ 07 Operatives □ 08 Laborers and Helpers □ 09 Service Workers

Essential Functions ?

Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.

Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.

Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.

Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.

Conducts educational sessions with physicians and other health care team members on documentation requirements.

Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff.

Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.

Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.

Job Requirements ?

Minimum Education
X Associate’s degree Required

Minimum Education
X Graduate of a Program in Discipline Preferred

Minimum Education
Bachelor’s degree Preferred

Minimum Education
□ Other □ Preferred □ Required

Required Skills
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Required Skills
Certifications:
□ Basic Life Support (BLS) □ Advanced Cardiovascular Life Support (ACLS) □ Pediatric Advanced Life Support (PALS) □ Neonatal Resuscitation Provider (NRP) □ Perioperative Nurse (CNOR) X Other: CCDS or CDIP preferred X Other: CS or CIC preferred

Required Skills
Licenses:
Licensed Registered Nurse (RN), RHIA, RHIT, Licensed Practical Nurse (LPN), or combination thereof Preferred.

Job: Please select a valid job field

Organization: Southern Tennessee Regional Health System – Lawrenceburg

Title: Clinical Documentation Spclst

Location: Tennessee-Lawrenceburg

Requisition ID: 7425-3350