Full time
Description
POSITION SUMMARY This position is responsible for improving the overall quality and completeness of clinical documentation for inpatient admissions, Same Day Surgery, Observation and Emergency Trauma Center encounters. This position facilitates concurrent modifications to clinical documentation through extensive interaction with physicians and other providers, Clinical Excellence and Patient Safety (CEPS), nursing staff, other patient care givers and HIM coding staff to ensure clinical severity and services rendered to patients are accurately reflected in the documentation. This requires review of appropriate diagnosis, procedures and working DRG's/APC's based on clinical indicators to assure appropriate clinical severity is captured. This position also ensures the accuracy and completeness of clinical information used for measuring and reporting physician data and Trinity Health outcomes. Educates members of the patient care team on documentation related issues on an ongoing basis. The Clinical Documentation Specialist reports to the Enterprise Director of HIM/CDI. MINIMUM QUALIFICATIONS AND REQUIREMENTS Licenses and Certifications Required Current or temporary RN license in ND or compact RN licensure or Licensed Practical Nurse or LPN designation required; OR Certified Clinical Documentation Specialist (CCDS) from ACDIS or Clinical Documentation Improvement Professional (CDIP) from AHIMA required. Educational Requirements Associate or Bachelor's Degree in Nursing required; OR Associate or Bachelor's Degree in Health Information Management (RHIT or RHIA) or other Clinical Healthcare field required. Experience Requirements A minimum of 3+ years clinical experience in an acute care or outpatient (Same Day Surgery, Emergency Room or Observation) setting is required; OR a minimum of 5+ years acute care, same day surgery, ER or observation) coding experience required. Special Skills or Training Requirements Dependable, self-directed. Critical thinking, problem solving, organizational and deductive reasoning skill. Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge an understanding of pathology/physiology of disease processes. Knowledge of medical record documentation requirements and computer literacy is required. Excellent written and verbal communication skills. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff. Willingness to learn and incorporate knowledge into day-to-day working environment: Knowledge of inpatient admission criteria; Understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, diagnosis and procedural coding, and impact of complications and comorbidities on the DRG, share knowledge with physicians and other health team members; Knowledge of Medicare reimbursement system and coding structures. Must be comfortable working in a time-oriented environment.
