Position Summary / Career Interest:

The Clinical Documentation Specialist (CDS) will review inpatient medical records as directed on admission and throughout hospitalization for completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM). The CDS will ensure effective and appropriate communication with the attending physicians, residents, fellows, PAs and APNs either verbally or in written methodology to suggest additional and/or more specific documentation. The CDS works closely with the HIM coding staff to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Responsibilities and Essential Job Functions

• Responsible for concurrent review of the clinical documentation in the medical records and query of the medical staff and other care givers as necessary via prompters/verbal communication to obtain accurate and complete documentation which appropriately supports the severity of patient illness and risk of mortality In collaboration with the physician, nurse, patient care coordinator, ancillary departments, and HIM coder, identifies and records principle diagnoses, secondary diagnoses, and procedures.
• Conducts initial concurrent review and ongoing re-review for all selected admissions to initiate the tracking process, document findings on the CDS worksheets, and identify other key pathway or quality indicators as appropriate. Utilizes clinical knowledge to identify need to clarify documentation in records, and utilizes strong commination skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation.
• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the accurate patient’s severity of illness and risk of mortality.
• Utilizes monitoring tools to track the progress of the program, through interpretation of on-site reports, monitoring reports and data.
• Shares findings with identified staff.
• Identifies areas that need focuses review through report analysis.
• Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
• Reviews coder feedback on completed worksheets and individual CDS tracking system reports as a means of continuous self-evaluation; discusses any issues or concerns with the CDI Supervisor.
• Educates Physicians and Staff regarding severity of illness and risk of mortality documentation. Collaborates with Physicians, Mid-level Providers, CDI Staff, and HIM Coders as well as works directly with individuals and departments where documentation improvement opportunities exist.
• Coordinates data and documentation compliance and collaborates on all aspects of the program to improve clinical documentation.
• Serves as an effective communicator of the clinical documentation improvement program’s vision and goals. Expressed ideas clearly and effectively (gaining agreement and/or understanding), by adjusting language, terminology, and style to the characteristics and needs of the audience as well as the venue for the communication.
• Effectively administers training sessions to new House Staff, Attending Staff, Nursing and Ancillary personnel.
• Develops and participates in presentations on clinical documentation improvement.
• Demonstrates competence in the areas of critical thinking, interpersonal relationships and technical skills.
• Manages his/her organizational responsibilities in a way that supports the achievement of departmental goals. Works effectively with others in the management team to accomplish organizational goals and to identify and resolve problems.
• Skillfully administers, directs and allocates all organization resources.
• Uses appropriate interpersonal styles and methods to develop a unit/team-wide spirit and intra-team and inter-team cooperation.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Associates Degree in Nursing from an accredited college or university. OR
• Foreign medical graduate (MD) with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license.
• 3 or more years of clinical experience in an acute care setting.

Preferred Education and Experience

• 3 or more years of Clinical Documentation, Case Management or Critical Care experience.

Required Licensure and Certification

• Licensed Registered Nurse (LRN) - Single State - State Board of Nursing OR
• Certified Clinical Documentation Specialist - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Certified Documentation Improvement Practitioner (CDIP) - American Health Information Management Association (AHIMA) for foreign medical graduates with MD.

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.