Clinical Documentation Specialist
Clinical Documentation Improvement - CA-Clinical Documentation Improvement
7:30 AM-4:00 PM
The Clinical Documentation Specialist is responsible for the evaluation of physician documentation, utilizing their clinical expertise to ensure the patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy.
Essential Duties and Responsibilities:
Responsible for daily evaluation of inpatient documentation in accordance with the Clinical Documentation Improvement Program requirements.
All inpatient documentation is reviewed for specificity of conditions/diagnosis and procedures.
Communicates with clinical staff when documentation needs further specificity.
Initiates compliant queries to Medical Staff as necessary based on evaluation of clinical information.
Ensures the accuracy and completeness of clinical information which is used for measuring and reporting physician and hospital outcomes.
Readily maintains a comprehensive understanding of coding rules and guidelines in order to facilitate communication with physicians.
Conducts follow up reviews to ensure points of clarification have been recorded in the medical record.
Follows up with physicians to get resolution of unanswered queries
Communicates with members of the medical staff on an ongoing basis to ensure that the documentation in the medical record adequately reflects the diagnoses being treated and the procedure performed.
Communicates effectively and comfortably with clinical staff to ensure comprehension of documentation requirements.
Serve as a resource to physicians to help link ICD-10 coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment.
Associates degree or higher
At least 3 years clinical experience, preferable in acute clinical areas (medical, surgical, ICU) preferred; HIM Coder (RHIA, RHIT, CCS) with at least 3 years inpatient coding experience
Must be a Registered Nurse and currently licensed to practice in the state of Louisiana or RHIA, RHIT or CCS
Willis-Knighton is an equal opportunity employer and thus, manages its employment and employee relations policies, practices and benefits without regard to age, race, sex, color, creed, religion, national origin, disability, veteran, or other protected status where otherwise qualified.