Job Description

The Clinical Documentation Specialist collaborates extensively with physicians, nursing staff, coding staff and billing staff to improve the quality and completeness of documentation of care provided at our hospital and clinics. Queries and educates medical staff.  Conducts focused chart reviews and documentation audits.  Works with providers to improve documentation to meet measure goals.  Is a resource to other staff focused in Charge Capture duties. 

Essential Job Duties:

  • Build and generate reports from the EMR. Review medical record for compliance including completeness and accuracy for severity of illness and quality.
  • Complete accurate and timely record review to ensure the integrity of documentation compliance. Understands and supports documentation strategies related to EMR and continues to educate self and revenue cycle team members.
  • Recognizes that documentation drives charge capture and will work diligently with all clinical team members to support charge capture initiatives.
  • Perform charge capture studies to identify areas of improvement and work with clinical department leads to facilitate resolution and on-going charge capture.
  • Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
  • Strategically educate members of the patient care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing and care management. This includes compliance updates from Medicare.
  • Effectively and appropriately communicate with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with other HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.
  • Complete well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
  • Will stay abreast of the regulations regarding documentation requirements and actively engage in continuing education and training WCH staff accordingly.
  • Is a resource to other staff focused on Charge Capture duties.

Other Duties:

  • Actively participate in meetings, including presentations for educational opportunities.
  • Will participate in various committees across the organization such as peer review committee and utilization review committee.
  • All other duties as assigned

Minimum Qualifications:

  • RN
  • Advanced computer skills and spreadsheet utilization.
  • Excellent written and verbal communication skills.
  • Demonstrates basic knowledge regarding HIM coding standards.
  • Analytic skills necessary to accurately assess patient medical records.
  • Excellent interpersonal skills and ability to work on a team to influence change.
  • Certification in clinical documentation through either AAPC or AHIMA, or ability to obtain within 1 year of hire.

Physical Requirements/Working Conditions:

  • Must be able to sit for long periods
  • Must be able to operate standard office equipment
  • Must be able to lift and carry up to 20 lbs
  • Must be able to work paying close attention to detail with frequent interruptions.
  • Ability to work in a fast pace environment.
  • Adequate hearing and vision for effective communication.
  • Follow complex instructions.
  • Think logically in following procedures and instructions.
  • Work well under stress, with interruptions and deadlines.
  • Effectively communicate dept needs to other departments.

Application Instructions

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