A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
$95,373.14•$143,059 Job Summary The CDIS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process is a key role. Essential Functions 1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors. 2. Reviews the medical record for completeness and accuracy for severity of illness (SOI) and quality using the current CDI software and electronic medical record. 3. Performs accurate and timely initial and concurrent record review 4. Recognize opportunities for documentation improvement 5. Facilitates appropriate clinical documentation to support accurate diagnosis coding and to ensure the level of service rendered to all patients is recorded. 6. Formulate clinically credible documentation clarifications (queries) to improve clinical documentation and capture of the appropriate principal diagnosis and all comorbidities. 7. Request documentation clarifications as appropriate for principal diagnosis, severity of illness, risk of mortality, risk adjustment and quality measures. 8. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation. 9. Timely follow up on all cases and resolution of those with clinical documentation clarifications. 10. Collaborate with HIM coding staff to promote complete and accurate clinical documentation and resolve discrepancies and appropriate DRG assignment. 11. Communicates with coders and resolves discrepancies 12. Conducts post discharge reviews and reconciliation of queries.
13. Performs all other related duties as assigned. Qualifications BSN Required or BS 4-6 years 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. Required Score (minimum of 70%) on the Clinical Competency Assessment (CCA) Organizational, analytical, writing and interpersonal skills Dependable, self-directed and pleasant Critical thinking, problem solving and deductive reasoning skills Knowledge of Pathophysiology and Disease Process Basic Computer skills•familiarity with Windows based software programs Knowledge of disease processes in all clinical specialties, anatomy & physiology and pharmacology and must have the ability to correlate abnormal lab results to disease processes Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System Knowledge of regulatory environment Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments Knowledge of Coding Guidelines & Quality Measures Registered Nurse New York•New York State Board of Nursing If
RN, RN NYS
License Upon Hire Required or Physician Assistant•New York State Board of Medicine If
PA, PA NYS
license Upon Hire Required
Score (minimum of 70%) on the Clinical Competency Assessment (CCA) White Plains Hospital Medical Center is an equal employment opportunity employer. White Plains Hospital Medical Center will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.
