Clinical Documentation Specialist - King's Daughters

• JOB SUMMARY
  • The Clinical Documentation Specialist is responsible for ensuring overall quality and completeness of clinical documentation. CDS works in collaboration with providers, coders, case manager and all members of the healthcare team to support accurate and timely clinical documentation in the health record. This role ensures that clinical severity is accurately and appropriately captures for the level of service rendered.
• DUTIES AND ESSENTIAL FUNCTIONS
  • Overall performance rating of below indicated essential job duties:
  • Improves overall quality and completeness of clinical documentation by performing admission and continues stay reviews using clinical documentation guidelines. Identifies the most appropriate principle diagnosis and chief complaint to accurately reflect severity of illness in compliance with applicable payor requirement and government regulations.
  • Confers with physicians to clarify information, obtain needed documentation, present education regarding the significance of the appropriate documentation needed to support clinical severity.
  • Conducts follow-up chart review to ensure agreed upon information has been included in the EMR documentation.
  • Assists coding specialists, as appropriate, with data abstract reviews and discrepancy resolution.
  • In collaboration with the team leader, creates edits and maintains data spreadsheets, graphs and data reports prepares data presentations and summaries for various hospital committees and administrative teams.
• EDUCATION/LICENSE/ CERTIFICATIONS/OTHER REQUIREMENTS
  • Minimum requirement:
    • Graduate from accredited program for Registered Nurses.
    • Current active licensure in the State of Kentucky as a Registered Nurse.
    • Two years of acute care experience as an RN.
    • Associate Degree in Nursing, BSN preferred
    • Familiarity with MS-DRG and the Inpatient Prospective Payment System (IPPS) including new CMS guidelines.
    • Familiarity of ICD-10 Official Coding Guidelines
  • Preferred qualifications:
    • Bachelor’s Degree in Nursing
    • One year of case management experience
    • Coding certification
• WORKING ENVIRONMENT
  • This job operates in a professional office environment routinely using standard office equipment such as computers.
  • The noise level in this position is usually moderate.
• PHYSICAL DEMANDS
  • Constantly required to maintain a stationary position behind a computer.
  • Frequently required to move about while rounding on departments.
  • Constantly required to communicate with people telephonically and in-person requiring talking and hearing.
  • Constantly required to operate a computer and telephone.
  • Occasionally required to lift and/or move up to 25 pounds.
  • Constantly required to lift and/or move up to 10 pounds.
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, and depth perception.

PI250518212