Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.

Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.

Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.

Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.

Conducts educational sessions with physicians and other health care team members on documentation requirements.

Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff.

Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.

Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.

Minimum Education:

High school diploma or equivalent

Associate’s degree in Nursing (Preferred)

Required Skills:

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.

Must be able to work in a stressful environment and take appropriate action.

Licenses:

RN in State of Michigan (if graduated from RN program)

Certifications: (one of the following is required if not an RN)

Certified Coding Specialist (C.C.S.)

Certified Professional Coder-Hospital (CPC-H)

Certified Coding Associate (CCA)

Registered Health Information Technician (RHIT)

Registered Health Information Administrator (RHIA)

Minimum Work Experience:

2 years hospital experience