The Clinical Documentation Specialist ensures clinical documentation is accurate, compliant and specific to reflect the severity of illness and risk of mortality of the patient.
- Facilitates concurrent documentation of the medical record to realize accurate and complete representation of the Severity of Illness and Risk of Mortality of the patient, resulting in the appropriate ICD-10 code/DRG assignment.
- Works collaboratively with medical, nursing, ancillary, and coding staff to improve the quality of chart documentation.
- Responsible for identifying complications and co-morbid conditions, specifying co-existing conditions and causal agents, and following-up with physicians responsible for care of the patient for appropriate documentation.
- Identifies the need to clarify documentation in the medical record and communicates with physicians face-to-face or using the appropriate “query” tools.
- Stays abreast of coding guidelines, reimbursement methodologies, regulatory compliance and quality based programs. Maintains thorough and current knowledge of clinical care and treatment options to critically assess appropriateness of documentation. Thorough clinical knowledge of disease processes, pathophysiology and pharmacology is required.
- Serves as a resource and educates physicians on linking coding guidelines and medical terminology to capture accurate final code assignment.
- Promotes mission, vision, and values of SCL Health, and abides by service behavior standards.
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
- Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate on clinical documentation requirements.
- Bachelor’s level degree in Nursing required.
- Active RN license in good standing required.
- Three (3) years of nursing experience in an acute care setting within the last 10 years or 1 or more year experience as a Clinical Documentation Specialist in an acute care setting within the past 2 years required.
- CDIP or CCDS certification preferred.
- CDI experience preferred.
- 3MCDIS and Epic preferred or ability to learn.
Organization: Platte Valley Medical Center, Brighton, CO
Primary Location: CO-Brighton
Department: SYS-Clinical Doc Improvement
Shift: Day Shift
Job Number: 18001309