CLINICAL DOCUMENTATION SPECIALIST-INPATIENT

FLSA Status

Job Role Summary

Essential Functions and Responsibilities

• Formulates and submits letters of appeal; creates an effective appeal utilizing relevant and effective clinical documentation from the medical record supported by current industry clinical guidelines, evidence based medicine, community and national medical management standards and protocols
• Performs accurate and timely concurrent clinical documentation reviews (POA, PSI,ROM, SOI and missing HCC) in an effort to capture the appropriate physician documentation that will result in accurate ICD-10 coding and DRG assignment that best reflects severity of illness and resource utilization
• Provides ongoing support and consultation to improve the overall quality of medical record documentation; serves as a clinical resource consultant to the HIM coding staff when coders require clinical decision-making and clinical interpretation to determine appropriate code assignment
• Develops teaching strategies and methodologies to improve program outcomes
• Provides primary clinical input into the ongoing planning and development of the Clinical Documentation Management Program (CDMP) in order to support and enhance multidisciplinary performance improvement initiatives; facilitates interaction with medical staff and HIM coding staff to provide collaborative link between departments to promote accurate and complete physician documentation
• Identifies educational needs of medical staff, health team members and HIM coding staff; plans and implements formal/informal introductory and ongoing orientation and training for multidisciplinary staff
• Maintains a strong knowledge of DRG methodology, Severity of Illness/ Risk of Mortality statistics and Coding Clinic guidelines
• Coordinates/collaborates with relevant facility departments (Case Management, Quality, HIM, Revenue Services, etc.) as clinical reviews are performed
• Participates in federal and state funded audit activity from appeal to legal proceedings (if needed) and maintains documentation of activity
• Assists with data analysis and summaries; performs mortality reviews in coordination with the Quality department

Job Requirements

• Indiana licensed Registered Nurse (RN) required
• Five years of strong and varied clinical experience in an acute care setting required
• Recent hospital experience, preferably ICU, CCU or strong Med/Surg preferred
• Knowledge of CMS Regulations
• Proficient in PC use, Microsoft applications and working knowledge of hospital department computer systems

Knowledge, Skills & Abilities

• Knowledge of regulatory requirements for appropriateness of admission
• Knowledge of Observation and Inpatient medical necessity
• Knowledge of POA/HAC and Core Measures
• Advanced problem-solving, analytical and critical thinking skills
• Working knowledge of Joint Commission (JC), Indiana State Department of Health

• Ability to work effectively with all levels of the organization, including physicians
• Knowledge of pathophysiology and disease process
• Knowledge of clinical documentation management tools and techniques
• Strong written and verbal communication skills
• Strong positive attitude; competent interpersonal skills
• Demonstrated leadership skills and strong organizational skills
• Ability to work independently; motivated to produce high quality outcomes
• Working knowledge of various software applications including: EPIC, Excel, and 3M preferred