Clinical Documentation Specialist

Position Summary

The role of the Clinical Documentation Specialist (CDS) in the home health and hospice agency is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation and insuring compliance with the Conditions of Participation and other regulatory requirements. The role is essential to the quality metrics of the agency.

Education/ Experience

• A Registered Nurse or Physical Therapist licensed in the State
• Experience in documentation review; OASIS certification preferred and working knowledge of ICD-10 coding guidelines is beneficial
• Experience working in home health and hospice agency setting for 3 or more years; 5 years is a plus.
• Experience with clinical documentation integrity and reportable quality data measures.
• Must be highly detail oriented.
• Exceptional analytical and critical thinking skills.
• Excellent written and verbal communication and interpersonal skills.
• Must have superior organizational and time management skills.
• Must have excellent computer skills.
• Knowledge of accepted quality assurance procedures.
• Knowledge of patient privacy laws.
  
  

ESSENTIAL DUTIES And RESPONSIBILITIES

Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job. They are intended to be accurate reflections of the principal duties and responsibilities of this position. These responsibilities and competencies listed below may change from time to time. Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position.

• Examination of clinical documentation through extensive review of the clinical record with a particular focus on SOC/ROC/Re-certs, discharge and all OASIS documentation.
• Ensures clinical documentation is complete and accurate and demonstrates the provision of skilled services.
• Completes medical record review of patient records in a timely fashion to permit successful OASIS submission.
• Collaborates with quality/education staff to identify opportunities for improvement in documentation for quality reporting and report based on trends identified through review of documentation to ensure continued improvement
• Stays current with OASIS guidelines, CMS regulations and other agency directives including knowledge of ICD-10-CM coding.
• Provide support to ensure that clinical information and quality data utilized in profiling and reporting is complete and accurate.
• Is a positive contributor in how documentation will affect quality outcomes in a timely manner
• Collaborate on state and federal audit requests with quality team.
• Identifies issues requiring clarification or additional information in the clinical documentation and initiates communication with the appropriate care provider using the established processes.
• Maintains an open and collaborative working relationship with agency staff.
• Participates in team meetings to discuss cases, questions and performance improvement strategies.
• Assists in other monitoring activities, special department projects or other needs as determined by the Agency Director and/or the Director of Clinical Optimization.
• Works closely with the Director to ensure the performance of the Clinical Support Specialist and the duties contained within that role meet expectations
• Ultimately responsible for the readiness of the claim for final release to billing.
• The CDS must exercise independent judgment, critical thinking, ability to work independently while following CMS guidelines, organizational policies, and procedures.