Clinical Documentation Specialist II

FLSA Status

Exempt

Job Role Summary

Under indirect supervision, the CDS (Clinical Documentation Specialist) II will facilitate and obtain appropriate provider documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of patient care.  Educate providers, nurses, coders, and other disciplines on documentation, coding, and reimbursement issues. Will identify quality of care issues in documentation and will seek resolution of issues through appropriate channels. Will work with the organizations denials team to help mitigate post payment denials and will review payer denial letters. Works independently majority of the time with a high degree of autonomy. Position may include remote and on-site working rotation.

The CDS II will contribute to content development, ongoing service line documentation improvement initiatives (including formal and informal provider education plans) and participate in department and organization projects related to documentation improvement.

Essential Functions and Responsibilities

• Performs essential functions of CDI I where assigned
• 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 quality (mortality, HAC, PSI) reviews in coordination with the Quality department.
• 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.
• Orientation of New CDS Staff: Conduct orientation for new CDS staff on quality chart review methods, compliant query composition, timely follow-up, and handling of queries from initial review to closure.
• Serves on internal hospital committees such as utilization review meetings, case management meetings as appointed by leadership
• Education Development: Oversee the development and delivery of ongoing formal and informal education programs for physicians, mid-levels, nursing, and other clinical staff.

Job Requirements

• Indiana licensed Registered Nurse (RN) required
• At least 5 years of Direct Clinical Documentation Integrity work experience required
• Five years of strong and varied clinical experience in an acute care setting required
• Experience of Observation and Inpatient Medical Necessity
• Certified Clinical Documentation Specialist (CCDS) preferred

Knowledge, Skills & Abilities

• Proficient in PC use, Microsoft applications and working knowledge of hospital department computer systems
• Knowledge of CMS Regulations

• Knowledge of regulatory requirements for appropriateness of admission
• Knowledge of Observation and Inpatient medical necessity
• Knowledge of POA/HAC and Core Measures
• Knowledge of a compliant query practice per ACDIS guidelines
• Knowledge of reimbursement methodologies (CMS and other payers)
• Advanced problem-solving, analytical and critical thinking skills
• Working knowledge of Joint Commission (JC), Indiana State Department of Health

(ISDH) and Centers for Medicare and Medicaid Services (CMS) regulations as they relate to medical documentation and health information management

• 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/prioritization skills
• Ability to work independently; motivated to produce high quality outcomes
• Working knowledge of various software applications