Purpose: Under minimal direction, the Clinical Documentation Specialist will provide active concurrent review, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect associated DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules.

1. Conducts initial and extended-stay concurrent review on selected admissions and documents findings per hospital policy.
2. Identifies co-morbidities and complications and documents appropriately.
3. Queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain   accurate and complete documentation.
4. Queries the medical staff to establish appropriate Present on Admission (POA) status of diagnoses if not clearly documented.
5. Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes.
6. Interacts with coding team as documentation issues are identified through the coding process for discussion with clinical staff.
7. Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement issues or missing documentation.
8. Communicates documentation issues clearly and succinctly to clinical care providers.
9. Makes an effort to capture all potential secondary diagnoses.
10. Identifies documentation issues and trends, and reports them to the CDI manager.
11. Interacts with Care Managers as they perform admission and continued stay review.
12. Monitors changes in law, regulations, rules, and code assignment that impact documentation and reimbursement
13. Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders.
14. Meets CDI program objectives, goals, and balance scorecard metrics.
15. Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
16. Ensures effective communications with key stakeholders.
17. Identifies trends and opportunities for improvement in clinical documentation.
18. Meets program quality and productivity guidelines and standards.
19. Collaborates with coding professionals to fully support the needs of clinical code assignment and communicates proficiently with coding professionals to resolve identified discrepancies.
20. Works effectively with CDI team members to accomplish departmental goals.
21. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements.
22. Demonstrates continued advancement in professional growth.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Current Alabama RN Licensure; Bachelor's Degree in Nursing preferred.

Three years in healthcare field such as clinical care, utilization review, health information management, or case management required.

Five years in healthcare field such as clinical care, utilization review, health information management, or case management preferred.

Certification in Clinical Documentation Improvement is preferred (CDIP, CCDS)

Skills/Knowledge: This position requires critical thinking, problem solving, ability of managing multiple priorities, able to work with little or minimum direct supervision, excellent writing skills, clear and accurate verbal communication skills, and ability to work in Microsoft Word, Excel, PowerPoint, and Outlook.  Must be able to read, write legibly, speak, and comprehend English. 

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.

Physical presence onsite is essential.