Position Summary

The Clinical Documentation Specialist (CDS) is responsible for reviewing clinical documentation in the  medical record to achieve more accurate and detailed documentation which will, in turn, improve the quality of patient care, more accurately portray the hospital/clinic’s quality outcomes ratings, reduce compliance risks and capture appropriate reimbursement. Utilizes the electronic health/medical record to audit medical documentation and facilitate accurate/complete measurement and reporting of physician and hospital/clinic outcomes. Identifies opportunities for improving documentation and educates physicians, clinical staff and HIM/coding staff accordingly. Must be able to respond to and interact with physicians and hospital/clinic staff in a courteous and collaborative manner.

Primary Duties

• Conducts concurrent and retrospective reviews of assigned medical records in a timely manner to ensure comprehensive documentation that accurately reflects clinical treatment, diagnoses, severity of illness and/or risk.
• Reviews electronic health/medical records for accuracy to substantiate medical billing.
• Follows up with physicians and other clinical staff to clarify ambiguous documentation or other medical record issues and assists in revisions as necessary to ensure accurate and complete documentation in the medical record.
• Identifies and records the most appropriate principal diagnoses, secondary diagnoses, complications/comorbidities and procedures to reflect the severity of illness and/or risk.
• Demonstrates an understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnosis and impact of procedures on DRG and/or CPT billing status and is able to impart this knowledge to physicians and other clinical staff.
• Analyzes electronic health/medical records to identify trends/issues, provides feedback to management and actively participates in clinical documentation improvement efforts and education opportunities for physicians/staff.
• Tracks and measures impact of improvement/education activities on desired physician and hospital/clinic outcomes.
• Provides training and education to internal customers related to compliant documentation responsibilities, coding and reimbursement issues and the clinical documentation system, as directed.
• Confers with HIM staff to ensure appropriate DRG and/or CPT billing status assignment and completeness of supporting documentation.
• Performs chart audits and second-level or pre-bill chart reviews, as needed.
• Maintains current knowledge of ICD-10 coding policies and procedures, DRG and/or CPT coding and Medicare/Medicaid reimbursement guidelines/regulations.
• Performs other duties as assigned.

Qualifications/Specifications

• Education: Graduate of an accredited program of nursing required. BSN preferred.
• Licensure/Certification: Current state Registered Nurse license or licensure from a state within the Nursing Compact required. ACDIS certification preferred (CCDS).
• Experience: Minimum of 3 years clinical experience in an acute or intensive care setting required. Knowledge of DRG system, ICD-10, Medicare Part A (for the hospital) and Medicare Part B billing and CPT coding (for the clinic) preferred.