Job Description

Clinical Documentation Specialist
Location
St. Dominic Hospital
Department
CARE MANAGEMENT - 9740
Employment Type:
Full Time 80
Shift:
Day
Other Shift Details:
Job Code:
14508

Clinical Documentation Specialist

Job Summary
The Clinical Documentation Specialist (CDS) is responsible for improving the overall accuracy and
completeness of clinical documentation within the medical record. The CDS performs record reviews
on selected medical records and documents findings and opportunities. Requests clarification of
clinician documentation which is incomplete, conflicting or non-specific. Facilitates modifications to
medical record documentation for accurate reflection of the patient's severity of illness, risk of
mortality, and resource utilization through interaction with clinicians, medical record coders, and
multidisciplinary healthcare team. Serves as a resource to providers for linking medical terminology
and coding guidelines for improved accuracy in code assignment. Facilitates accuracy and
completeness of documentation used for measuring and reporting provider and hospital outcomes.
Maintains accurate and complete record review and query outcome to comply with departmental and
regulatory guidelines. Understands and complies with policies and procedures related to
confidentiality of medical records. Identifies opportunities for intradepartmental and
interdepartmental operational improvements. Participates in CDI program related meetings, clinician
education, staff development, departmental activities and opportunities. Consistently demonstrates
actions and values of the FMOLHS Mission as daily duties are performed
Job Requirements

Experience - Must possess one of the following experience requirements: 1. RN
with 3 years clinical nursing experience in an acute care facility or 2. RHIA or RHIT with 5 years acute care coding experience with CCS certification.
Education - Associate's or Bachelor's degree in Nursing or HIM field
Special Skills - Knowledge of ICD-10 Codes Prefer experience in Documentation Improvement.
Licensure- Mississippi licensed RN
Essential Functions
Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.Facilitates documentation and clarification of clinical information to ensure complete and compliant medical records that accurately reflect the level of service rendered.Performs admission and continued stay reviews using appropriate documentation guidelines.Maintains and completes the DRG Clinical Worksheet on assigned patients; enters information in tracking database after final DRG assignment.Educates physicians regarding documentation requirements and coding guidelines.Maintains daily productivity records and submits to Director of HIM as scheduled.Participates in meetings with coding personnel on a weekly basis.Attends Medical Staff division meetings as assigned by the Director of HIM.Trains new documentation specialists as necessary.Keeps abreast of current trends in areas of documentation and coding.Additional Responsibilities: Supports the hospital's Christian mission, philosophy, values and goals.Participates in and supports established Performance Improvement Programs.Attends JCAHO and mandatory inservice programs, completes fraud and abuse educational program on an annual basis.Observes hospital dress code and maintains appropriate conduct and appearance.Maintains confidentiality of all information regarding patients, families, physicians and hospital personnel.

Application Instructions

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