Clinical Documentation Specialist

Job Title: Clinical Documentation Specialist
Job Type: Full time, remote

Facilitates improvement in overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation. Remote assignment could be considered depending on the candidate.

Reports to: HIM Director
FLSA: Non-exempt

Essential Functions

• Conducts daily concurrent reviews of medical records to identify missing, vague and/or incomplete diagnoses and procedures.
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and issued queries have been answered by providers.
• Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise, and LifePoint Health query policy.
• Participates in department and facility Quality and Performance initiatives.
• Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
• Conducts education sessions with providers and other health care team members on documentation requirements.
• Prepares and presents education programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance, and coding staff.
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
• Maintains education record which meets minimum CEU requirements required for continued licensure and/or certification.

Non-Essential Functions

• Acts as a strong advocate of the CDI program while educating physician, clinical, and other staff on the importance of clinically accurate documentation and the capture of data through ICD-10 coding. Demonstrates understanding of the importance of non-leading queries and communication with providers.
• Conducts CDI onboarding education of all new admitting physicians as part of the hospital orientation program.
• Reviews clinical issues and identified query response concerns with physician champion/advisors.
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
• Works closely with case management, quality management, risk/compliance management, and medical staff to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff leadership and other health care disciplines to assure effective monitoring and successful completion of identified plans for improvement.
• Safeguards the patient's right to privacy by judiciously protecting information of the patient and medical record as per HIPAA guidelines.
• Performs other duties as assigned.

Minimum Requirements

Education:

• Associate's degree or higher in Nursing, or certification in RHIA, RHIT, CCS or combination thereof
• Required Graduate of a Program in Discipline: Preferred
• Bachelor's Degree Nursing (BSN): Preferred

Work Experience:

• Three years of Healthcare Experience Required

Skills:

• Requires critical thinking skills, decisive judgement and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.
• Must be comfortable working in multiple computer applications and navigating EMR.
• Must be a good communicator and demonstrate functionality with attending meetings and collaborating with peers and providers via email and Microsoft Teams.
• Must have thorough understanding of ICD-10 Official Coding Guidelines for Coding and Reporting and AHA Coding Clinic; HCPCS/CPT coding systems and CPT Assistant and Coding Clinic for HCPCS guidelines; Medicare Outpatient Prospective Payment System (OPPS), and Ambulatory Payment Classification (APC).

Functional Demands

Populations Served: Does not treat of care for patients.

Protected Health Information

Type of Protected Information Accessed: Demographic; Clinical; Insurance; Complete Medical Record

Bloodborne Pathogens Exposure:

While performing this job, occupational exposure is present for all employees - unless remote worker

Physical Requirements - Physical Dexterity and Effort: Rarely

Bending/Stooping: Occasionally; Climbing: Rarely; Keyboard Data Entry: Constantly; Kneeling: Rarely; Lifting/Moving Patients: Rarely; Reaching: Occasionally; Repetitive Foot/Leg Movements: Rarely; Repetitive Hand/Arm Movements: Constantly; Running: Rarely; Sitting: Frequently; Squatting: Rarely; Standing: Occasionally; Walking: Occasionally; Pushing/Pulling: 0-25 lbs: Rarely; 26-75 lbs: Rarely; over 75 lbs: Rarely; Lifting/Carrying (non-patient): 0-25 lbs: occasionally; 26-75 lbs: Rarely; over 75 lbs: Rarely.

Visual Acuity, Hearing and Speaking: Rarely

Audible Speech: Constantly; Hearing Acuity: Constantly; Smelling Acuity: Rarely; Taste Discrimination: Rarely; Vision: Depth Perception: Constantly; Vision: Distinguis Color: Rarely; Vision: Seeing Far: Occasionally; Vision: Seeing Near: Constantly

Biological: Rarely

Biohazardous waste/hazards: Occasionally, Blood and/or bodily fluids: Occasionally, Communicable diseases/pathogens: Occasionally,

Chemical: Rarely

Asbestos or lead: Rarely; Cytotoxic Chemicals: Rarely; Dust: Occasionally; Hazardous Chemicals: Rarely; Gases/Vapors/Fumes: Rarely; Hazardous Medication: Rarely; Latex: Occasionally

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.