Clinical documentation specialist [h1.location_city]

Description

Job Summary

The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy quality and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patients clinical status and care provided. The CDS collaborates with providers through education and the physician query process ensuring medical records accurately reflect patient severity of illness and support continuity of care appropriate quality metrics and regulatory compliance.

Essential Functions

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy ensuring assigned codes reflect patient severity and acuity.
• Adheres to corporate recommended CDI workflows and uses CDI and medical records software such as 3M 360 Encompass and Iodine Interact to support documentation practices.
• Utilizes approved physician query processes to clarify documentation ensuring queries are compliant necessary and non-leading and follows up daily on unanswered queries.
• Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
• Tracks CDI activities within CDI software accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
• Provides education and training to providers explaining recommendations for documentation improvement and offering insights through individual or group sessions.
• Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
• Leads physician education initiatives developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
• Monitors regulatory changes in coding documentation and quality metrics ensuring compliance with updated standards and sharing information with staff as needed.
• Creates and submits accurate reports in a timely manner maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

Knowledge Skills and Abilities

Licenses and Certifications

INDNC

Required Experience :

IC

Key Skills

Environment,Ado,Carpentry,Drafting,Front Office Management,Airlines

Employment Type : Full-Time

Experience : years

Vacancy : 1