Clinical Documentation Specialist - Peri-Operative

Job Summary

The peri-operative Clinical Documentation Specialist role (CDS) is a hybrid role combining clinical documentation and case management expertise. The primary purpose of this role is to have a comprehensive, systematic approach to a patient’s health record before, during, and after surgery, with an emphasis on patient and record optimization. The role is a specialized position that combines oversight of the medical record with coordination of patient care focusing on regulatory compliance, improving patient outcomes, and managing healthcare resources efficiently. The role simultaneously manages patient cases, ensuring complete and accurate medical record documentation for coding and reimbursement, while collaborating with the healthcare team to improve quality of care and documentation. The CDS is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. The peri-operative CDS, working under the direction of the CDI Team Lead and Case Management director, in conjunction with office managers, directors, and lead physicians, will utilize documentation and coding expertise to identify and facilitate modifications to quality and completeness of medical record documentation. Through concurrent, retrospective and prospective evaluation and assimilation of the objective and subjective data, documented within the medical record along with communication with the care team, the CDS will be responsible for educating providers and achieving improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/complexity of the patient while providing specific and complete information to be utilized in coding, profiling, and outcomes reporting of both the facility and the physician. The peri-operative CDS will facilitate compliance with regulations and payer policies and guidelines while bridging clinical care with coding and administrative needs. 

Performance: Position Specific Essential Functions

• Onsite clinical collaboration working directly with the healthcare team to attend meetings, provide education, and discuss specific cases.
• Collecting patient information related to diagnosis and care by conducting daily chart reviews.
• Assessing documentation validity utilizing CDI and utilization review analytic software and critical thinking skills to: modify risk by developing recommendations for risk reduction such as patient safety indicators; improve the clinical depiction of the patient leading to better quality outcomes in surgical settings; contribute to hospital efficiency, cost savings, and appropriate use of resources; provide data for performance metrics and quality initiatives.
• Identifying and communicating query opportunities with providers (for needed documentation support, ambiguity, or conflict).
• Meeting productivity requirements established in department standards.
• Collaborating with physicians, nurses, and other clinical staff to clarify documentation, address gaps, identify opportunities for improvement in the documentation process, and provide education on best practices for accurate and compliant record keeping.
• Upholding the integrity of the hospital medical record by complying with organizational, legal, ethical, and regulatory requirements.
• Manage patient cases from admission through discharge by ensuring that necessary documentation supports the care plan and subsequent billing.
• Providing superior customer service to customers and coworkers with professional conduct and respectful behavior.
• Strong interpersonal skills that allow for effective communication with different levels of hospital personnel
• Solid verbal and written communication skills required.
• Organization, prioritization, critical thinking, and attention to detail are needed.
• Basic computer and office equipment knowledge; Electronic Medical Record training provided.
• Prior knowledge of medical and pharmacology terminology required.
• Performs other duties as assigned.

Qualifications

Education

• Required
  • High School Diploma
  • Associate's degree in nursing
• Preferred
  • Bachelor's degree in nursing

Experience:

• Required
  • Five years of experience in acute care/hospital setting
• Preferred
  • One year of experience in clinical documentation improvement, utilization review, and/or acute care case management

Certification/Licensure:

• Required
  • Registered Nurse (RN) with Authorization to Practice in the State in Texas
• Preferred
  • RHIT/RHIA/CDIP/CCDS or relevant clinical documentation certification