Clinical Documentation Specialist Job Description
Clinical documentation specialist
provides daily clinical evaluation of the medical record documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
Clinical Documentation Specialist Duties & Responsibilities
To write an effective clinical documentation specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical documentation specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Updating DRG worksheet to reflect any changes in patient status, procedures/treatments, and conferring with physician to finalize diagnoses
Conferring with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures
Perform concurrent / retrospective medical record reviews to monitor compliance
Assist with clinical services
Generate and assist with analysis of Reports
Collaborate with Risk Management, Infection Control, Guest Relations, Patient Safety, Safety Department and others to maximize compliance with Regulatory Standards
Assisting in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate
Extensively reviewing all physician and clinical documentation, lab results, diagnostic information, and treatment plans and capturing appropriate information on worksheets
Utilizing clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption
Reviewing medical record every 24-48 hours as appropriate
Clinical Documentation Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Documentation Specialist
List any licenses or certifications required by the position: CCDS, CDIP, RHIA, RHIT, BLS, OASIS, CCS, CDS, CCM, CCDIS
Education for Clinical Documentation Specialist
Typically a job would require a certain level of education.
Employers hiring for the clinical documentation specialist job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Health Information Management, Science, Medical, Healthcare, Graduate, Associates, Health, Communication
Skills for Clinical Documentation Specialist
Desired skills for clinical documentation specialist include:
Clinical documentation requirements
Pathophysiology
Regulatory environment
Referral policies and procedures
ICD-9-CM
Clinical documentation requirements that identify clinical conditions
Procedures
Federal
Acute care nursing experience
Inpatient admission criteria
Desired experience for clinical documentation specialist includes:
Communicating with physician to ensure that request for documentation has been noted
Conducting follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart
Following established process for follow-up reviews and physician communication
Reviews clinical issues with coding staff to assign working DRG using software
Participating in concurrent performance improvement activities and on-going MR review activities
Reviewing tracking data in conjunction with established benchmarks
Clinical Documentation Specialist Examples
1
Clinical Documentation Specialist Job Description
Job Description Example
Our innovative and growing company is looking for a clinical documentation specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical documentation specialist
- Identifies all procedures and secondary diagnoses for co-morbidities/complications and documents appropriately using the CDIS Module in 3M
- Applies federal and state documentation and coding (ICD 9 and ICD 10) guidelines to ensure physician and hospital compliance
- Maintain document tracking system
- Collaborate with CTM to determine to issues in regulatory documentation
- Create study-specific document checklists in collaboration with the CTM and medical research
- Work collaboratively with Health Information Management Team to develop the guidelines for concurrent review of the medical record
- Monitor performance of CDI’s and be able to produce data demonstrating performance efficiency and productivity of each CDI upon request
- Coordinate across CDS’s to address and resolve key issues and concerns
- Work with the physician staff, Case Management and nursing to assure appropriate DRG classification accurately reflects severity of illness and risk of mortality through proper documentation
- Work with the Case Management Department to develop the best approach for initial education of the physicians and regular updates
Qualifications for clinical documentation specialist
- Experience in UR, Case Management, and/or Clinical Documentation Improvement $
- Maintain up-to-date knowledge of coding issues and guidelines by attending seminars and reviewing professional literature as necessary
- Identify opportunities to develop and implement plans for both formal and informal education of physician, Case Management and HIM staff
- Develop targets for severity of illness and risk of mortality reports showing progression towards the same hospital administration
- Ensuring complete, accurate and timely documentation for clinical communication and charge capture based on medical record documentation
- Accurate establishment of clinical documentation and charge capture, researching and resolving charge system problems and analysis of current systems for purposes of identifying system improvements
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Clinical Documentation Specialist Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of clinical documentation specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical documentation specialist
- Utilizes advanced knowledge of functional health patterns physiology, pathophysiology, and psycho sociology in documentation efforts and other projects related to Outcomes Management
- Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcome
- Identifies documentation trends and issues and reports these to HIM Director, CDI Manager, CDI Supervisor, the inpatient coding management and staff
- Educates nursing staff, patient caregivers and coding staff on compliant documentation opportunities, coding and reimbursement issues provides clinical expertise to the coding staff
- Ability to analyze complex clinical scenarios and apply critical thinking
- Following orientation period, meets established productivity targets for review of an average of 8-10 new inpatient medical records per day and 12 -15 re-reviews
- Maintains an accuracy rate of 90% or greater in identifying correct concurrent initial and possible DRG when 2 or more diagnoses meet definition of PDX
- Educates all internal customers on compliant documentation responsibilities, coding and reimbursement issues, performance improvement methodologies
- Be part of a regional team that facilitates improvement in the overall quality, completeness and accuracy of medical record documentation
- Assist with necessary modification to clinical documentation through extensive interaction with physicians
Qualifications for clinical documentation specialist
- RN, CCDS or CDIP a plus
- Must possess at least five years of acute hospital nursing experience
- Current RN license required with Critical Care, OR, ER experience preferred
- Requires manual dexterity to grasp and handle records and to operate a PC computer in the course of work
- Ability to perform well in a fast-paced, team environment and to manage time effectively
- Prior experience as a clinical documentation specialist
3
Clinical Documentation Specialist Job Description
Job Description Example
Our innovative and growing company is looking for a clinical documentation specialist. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical documentation specialist
- Develop and implement plans for education of physicians, nursing and ancillary staff on documentation improvement
- Work with Clinicians and Coders to successfully implement the Compliant Documentation Management Program (CDMP) for MS-DRG and AP-DRG payers on assigned Hospital Units
- Performs complex reviews of patient’s medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM)
- Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment
- Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient's condition, treatments, and any co-morbidities
- Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews
- Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement
- Monitors changes and updates in regulatory requirements for clinical documentation
- Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues
- Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement
Qualifications for clinical documentation specialist
- Current WA RN licensure
- 5+ years recent clinical experience in an acute inpatient hospital setting
- Ability to organize and prioritize with attention to detail
- Adept with Windows PC and Microsoft Office products
- Current Registered Nurse License in the State of practice
- Certification will be required within 1 year and maintenance of required Continuing Education Units (CEU)
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Clinical Documentation Specialist Job Description
Job Description Example
Our innovative and growing company is hiring for a clinical documentation specialist. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical documentation specialist
- Perform QC checks on documents supporting trials to ensure complete
- Conducts initial and continued-stay concurrent reviews (every 2 days) on inpatient admissions and documents findings using the CDIS Module in 3M, denoting all key information utilized in tracking process
- Facilitates appropriate clinical documentation, to ensure that the severity of illness and intensity of services provided are accurately reflected in the medical record
- Serves as a resource for clinical documentation and provides support to associates regarding complex patient issues and the impact on clinical documentation needs
- Assists the Coding Manager with the education of all members of the health team on clinical documentation opportunities, coding and reimbursement issues
- Establishes collaborative practice and maintains open communication with other nursing personnel, physicians and health care professionals regarding clinical documentation
- Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient’s chart
- Facilitates the acquisition and application of clinical, theoretical and financial knowledge and decision-making skills of department staff, physicians, and other health care provides
- Assesses learning needs, designs, implements and evaluates systems/processes for health care providers to improve patient outcomes
- Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary
Qualifications for clinical documentation specialist
- Possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Anthelio Healthcare Solutions
- Complete a clinical exam and achieve an 80% passing score
- Must be able to travel to various locations (≈20%) as required
- Able to set and organize own work priorities, and adapt to change when needed
- Able to spend majority of time utilizing a computer, monitor and keyboard
- Able to perform some lifting and/or pushing/pulling up to 20 pounds
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Clinical Documentation Specialist Job Description
Job Description Example
Our company is growing rapidly and is looking for a clinical documentation specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical documentation specialist
- Educates physicians and the medical staff regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
- Collaborates with ancillary departments regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge
- Manage the improvement of the overall quality and completeness of clinical documentation through interaction with physicians, nursing staff, and other patient caregivers and HIM coding staff
- Be a part of a regional team that facilitates improvement in the overall quality, completeness and accuracy of medical record documentation
- Analyze clinical information to identify areas within the medical record for potential gaps in physician documentation
- Work with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
- Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department
- Enter clinical review data and related anticipated follow-up in PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG
- Set-up and maintain the clinical TMF in accordance with the TMF Reference Model, ICH GCP, FDA regulations and policies
- Receive, review for completeness, categorize, and file essential documents into the clinical TMF
Qualifications for clinical documentation specialist
- Associate’s or bachelor’s undergraduate degree in Health Information Management or Nursing strongly preferred
- A minimum of one year of experience in the role of Clinical Documentation Specialist or years of clinical skills in conjunction with prior coding experience
- Case Management/ICU experience
- BSN from NLNAC and/or CCNE accredited school of nursing or college strongly preferred
- Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines
- Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems