What are the responsibilities and job description for the Clinical Documentation Specialist position at Med Center Health?
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Position Summary
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Provides clinically based concurrent and retrospective review of inpatient medical records documentation for utilization, severity of illness, risk of mortality and identifies opportunities for improving the quality of medical record documentation and confers with the caregiver regarding additional documentation required. Reviews are determined both internally and by requirements/requests of external payers or regulatory agencies. Reports quality of care outcomes and obtains accurate and compliant reimbursement for acute care services. Educates members of the patient care team regarding documentation guidelines. Collects clinical documentation improvement data for analysis and report generation. Facilitates and enhances the coding and DRG process alignment between physicians and coding staff.
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Minimum Qualifications
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Work Experience
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Three years of recent critical care experience in an acute care hospital setting, three years recent Case Management and/or Utilization Review experience in acute care hospital setting (OR) five years recent Medical/Surgical experience in an acute care hospital setting required.
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Education-
Graduate of a school of nursing required.
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Bachelor’s degree in nursing or related field preferred.
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Certifications/Licensure-
Kentucky RN license (OR) RN license in a State recognized by the Kentucky Nurse Licensure Compact Act required effective June 1, 2007.
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Job Specific Performance Standards
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The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.
- Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided to acute care patients are accurately reflected in the medical record. Ensures an appropriate DRG is assigned to each patient with a DRG based payer, and an appropriate reimbursement is received for the level of services rendered. Ensures the working DRG is entered in the hospital computer system. Accurately enters required information in the medical record and computer system.
- Reviews clinical issues and performs clinical validation reviews with HIM coding staff to assign an accurate working DRG.
- As appropriate, participates in Performance Improvement data collection, evaluation and recommendations for improvement. Refers quality issues to the Department Director.
- Ensures the accuracy and completeness of clinical information is used for measuring and reporting physician and hospital outcomes.
- Updates the DRG Worksheet to reflect changes in status, procedures/treatments, and confers with physician to finalize diagnoses. Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient’s chart.
- Educates internal customers on clinical documentation opportunities, clinical validation of assigned diagnoses, coding and reimbursement issues, as well as performance improvement methodologies.
- Serves as a member of the CDI Task Force and Clinical Documentation Team, assists with special projects as needed and performs related duties as assigned. Tracks response to CDI and trends completion of DRG worksheets.
- Communicates effectively with patient care team to clarify issues and collaboratively obtain complete and accurate documentation in the medical record.
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