Job Description

Clinical Documentation Specialist - Clinical

SUMMARY: Conducts clinically-based concurrent and retrospective review of inpatient medical records to evaluate whether the clinical documentation is representative of the severity of illness of the patient and risk of mortality relative to the quality of care outcomes and reimbursement compliance for the acute care services provided. Duties include focused APR-DRG studies, quality reviews, and high risk retrospective reviews. Collaborates extensively with physicians, nurse practitioners, physician assistants, nursing staff and other ancillary caregivers and health information management coding staff, to improve the quality and completeness of documentation of care. Evaluates hospital admission criteria and conduct concurrent review of initial, regular, and extended stay reviews on a majority of admissions. Serves as an expert resource for RN case managers and care providers who assign the correct patient status and level of care, and support the medical necessity of services. Conducts new hire and ongoing education of medical staff, residents, nurse practitioners and physician assistants regarding high-quality clinical documentation guidelines and practices. Participates in performance improvement activities such as Maintenance of Certification (MOC) initiatives. Attends regular forums such as morning and afternoon rounds, and assists in the presentation, analysis and trending of statistical data for specific patient populations. Writes clinical appeal responses for APR-DRG denials.

JOB REQUIREMENTS: Masters Degree in Public Health or Health Administration required. 12 Months in same or similar position required. Certified Coding Specialist (CCS) certification required. In lieu of the above listed Masters Degree and work experience, a suitable and acceptable substitute is a Bachelors Degree in Nursing or Medicine, or the foreign equivalent and 5 years of progressive work experience in the same or similar position.

POSITION DETAILS: Full-time, 80 hours per pay period, M-F, 8-5


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