Clinical Document Specialist

• Employment Type:

• Full time

• Shift:

• Day Shift

• Description:

• GENERAL SUMMARY AND PURPOSE

• The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the patient's severity of illness and risk of mortality by improving the quality of the physician's clinical documentation.

This involves extensive record review, interaction with physicians, Health Information Management (HIM) professionals, and nursing staff. Active participation in team meetings and education of medical, nursing, and ancillary staff is a key role.

• REQUIREMENTS

• : + Registered Nurse, BSN preferred;or Certified Physician Assistant (PA-C).RHIT, RHIA, or CCDS, CDIPcertification a plus. Proof of RN license is needed only in state of residence. + 3 to 5 years varied hospital clinical experience required. Critical care or strong medical surgical background preferred. + Ability to pass written clinical competency exam.

• WHAT YOU WILL DO

• + Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.

+ Ability to quickly learn and develop the skills necessary to performthe CDS role, including ability to accurately input relevant data into3M 360 Encompass and Cerner PowerChart(special purpose software). + Revenue Management + Ensurephysician documentation contains adequate indicators to support the coding of diagnoses representative of eachpatient. + Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications. + Formulates credibleand compliantclarifications to improve clinical documentation of principle diagnosis, co-morbidities,evidence of indicators representing conditionspresent on admission (POA), and quality core measures. + Facilitates modifications to clinical documentationof the medical recordthrough extensive interaction with physicians, nurses, and ancillary staff. + Developsand implement plans of education of physicians, nursing, and ancillary staff on documentation improvement. + Reviews inpatient medical records forallpayer populations on admissions andthroughouthospitalization. + Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation. + Able to communicateeffectively and appropriately with individuals at all levels of the organization. + Actively participate in cross functional Task Force meetings. + Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Able to effectively communicate with HIM staff and resolve discrepancies. + Responsible for completing all annual regulatory compliance education, as well as CDS-specific assigned education. + Understand and support compliant documentation strategies. + Knowledge of pathophysiology and disease process. + Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred. + Excellent organizational, analytical, and writing skills. + Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills. + Excellent time management skills and the ability to manage multiple priorities effectively. + Dependable and self-directed.

• Our Commitment
• Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings.

By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. EOE including disability/veteran