CLINICAL DOCUMENTATION SPECIALIST RN

Overview

The Clinical Documentation Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation. This nurse is responsible for concurrent review of the clinical documentation in the medical record to facilitate appropriate physician documentation to accurately reflect patient severity of illness, risk of mortality, and DRG assignment. This nurse is accountable for meeting casemix goals, which translate into financial targets, and severity of illness, risk of mortality, and quality indicator goals, which impact hospital and physician profiling.
Responsibilities

Demonstrates excellent customer service.
Contributes to organization success targets for patient satisfaction by meeting the Case Coordinator Expectations for Customer Satisfaction.
Contributes to organization success targets for net operating margin.
Ensures the availability of accurate and timely information.

In collaboration with the physician, identifies principal and secondary diagnoses and procedures, and assigns a working DRG. Identifies options and relative weights when more than one diagnosis may be assigned as principal. Performs a thorough chart review to identify complications and comorbid conditions.
Conducts the initial concurrent review process for all selected admissions to initiate the tracking process and documents findings on the DRG worksheet.
Demonstrates an understanding of the importance of and makes an effort to capture ALL potential secondary diagnoses for profiling purposes.
Screens record for key quality indicators and concurrently addresses issues with physicians
Appropriately and assertively communicates with finesse concurrently with physicians when requesting clarification or documentation for severity of illness, risk of mortality, DRG assignment, or quality indicator.
Utilizes tools available to educate physicians as to clinical documentation.

Utilizes monitoring tools to track the progress of the DRG Assurance program, interprets tracking information, and develops and implements action plans for improvement.
Assists in the development and distribution of APR/DRG physician profiling reports.
Develops tracking reports to demonstrate effectiveness of program, analyzes findings, develops and implements action plans. Prepares administrative reports for presentation to Executives. Maintains accountability for meeting goals.
Analyzes data reports to identify deficiencies in own practice, and actively seeks education to improve. Collaborates with HIM coders in this process.
Analyzes data reports to identify patterns by physician or patient population, and targets action plans to resolve issues.

Plays an active role in developing and delivering education to physicians specific to documentation challenges.
Coordinates and facilitates communications between coders and payers/review agencies. Reviews DRG changes requested by payers and collaborates with coders in constructing appeals.

Demonstrates excellent communication skills, negotiation skills, diplomacy, finesse and assertiveness.
Builds and nurtures professional, effective relationships with all members of the Healthcare team, particularly physicians.
Manages conflict effectively, striving for win-win outcomes.
Maintains complete confidentiality of patient information, in addition to hospital and individual practice pattern data.


Qualifications

EDUCATION/EXPERIENCE
Education/Licensure/Certification Required:
RN with current license in State of Michigan.
Bachelor’s degree or willingness to complete within three years

Would consider a foreign MD with a CCDS certification.
Experience preferred/required:
Minimum of 5 years clinical experience in an acute care setting required.

Utilization Management/Clinical Documentation Integrity experience strongly preferred

KNOWLEDGE/SKILLS/ABILITIES
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age-specific needs and the elements of disease process and related procedures.
Excellent communication and critical thinking skills.
Working knowledge of Medicare reimbursement and coding structures.
Ability to work independently in a time oriented environment.
May be exposed to all patient elements, e.g. blood borne pathogens, and to environmental hazards such as anesthetic gases or elements.
Demonstrates good computer skills.

PHYSICAL REQUIREMENTS
Able to sit for extended periods of time
Able to be on feet and walk for extended periods of time
Able to lift, bend, and carry

WORKING CONDITIONS/PHYSICAL DEMANDS
Ability to maintain punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.
Constant repetitive leg/arm movement, computer data entry.
Frequent sitting, standing, crawling.
Occasional lifting floor to knuckle, lifting 12" to knuckle.
Occasional lifting shoulder to overhead, carrying, pushing.
Occasional pulling, stooping, reaching, climbing, squatting.
Occasional crouching, kneeling, crawling, balancing.