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, CDIP

certification 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 perform the CDS role, including ability to accurately input relevant data into 3M 360 Encompass and Cerner PowerChart (special purpose software). Revenue Management Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient. Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications. Formulates credible and compliant clarifications to improve clinical documentation of principle diagnosis, co-morbidities, evidence of indicators representing conditions present on admission (POA), and quality core measures. Facilitates modifications to clinical documentation of the medical record through extensive interaction with physicians, nurses, and ancillary staff. Develops and implement plans of education of physicians, nursing, and ancillary staff on documentation improvement. Reviews inpatient medical records for all payer populations on admissions and throughout hospitalization. Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation. Able to communicate effectively 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. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we're 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.