Under the general supervision of the Director of HIM, the Clinical Documentation Specialist (CDS) is responsible for coordinating the review of concurrent inpatient clinical documentation and data. The CDS facilitates accurate documentation for severity of illness and quality documentation in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, clinical informatics, and nursing staff. The CDS works with providers to ensure clinical disease processes are accurately documented and that the documentation appropriately reflects the patient's severity of illness and DRG. Active participation in team meetings and education of staff in the CDI process is a key role.
- Analyzes documented data and information to assist in determining areas for improvement in documentation and proper DRG selection. Provides concurrent reviews of inpatient medical records, identify potential documentation deficits, and clarifies with providers (physicians, PAs, ARNPs, etc.) to ensure the appropriate severity of illness is documented.
- Has a working knowledge of correct principal diagnosis and principal procedures. Understands ICD-10 coding and DRG principles in accordance with coding and reimbursement guidelines. Is able to validate DRG grouping and relate grouping methodology to documentation needs.
- Utilizes documentation software and EMR templates to maintain accuracy of data for tracking purposes.
- Formulates appropriate documentation clarification queries using established guidelines to clarify questionable or incomplete documentation.
- Identifies clinical or system/process breakdowns and improvement opportunities and refers them to the appropriate areas (CM, Risk, Quality) for resolution.
- Acts as a documentation resource for Nursing, Case Managers, Coding, and Physicians. Actively participates in the education of healthcare team members on current healthcare economic issues impacting practice patterns, reimbursement and positive patient outcomes.
- Attends professional in-services and coding in-service programs.
- Participates on hospital committees as assigned. Performs similar or related duties as assigned. Knows fire, disaster and safety procedures and regulations as pertains to the work area.
- Associates degree, or other two year college equivalent. Major required: Nursing. Graduate of an accredited RN Education Program, BSN preferred.
- Minimum of five (5) years nursing experience in Med/Surg., Critical Care, or similar nursing experience.
Required Licenses, Certifications, Registrations
- State of Florida RN license. ICD-10 training and certification prefered. Certified Documentation Improvement Practicioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) credentials preferred.