Clinical Documentation Specialist

FirstHealth of the Carolinas

Job Description

Clinical Documentation Specialist: Inpatient
Conducts initial and extended-stay concurrent reviews on all selected admissions, and documents findings within the CDS worksheet, denoting all key information utilized in the tracking process.
Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, 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 patient's severity of illness and risk of mortality.
Improve the overall quality and completeness of physician clinical documentation.
Confers with physicians face to face or via APR/DRG/query to clarify information, obtain needed documentation, and present opportunities to educate regarding the significance of appropriate documentation needed to support the clinical severity of the patient.
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRG for at least 85% of identified populations. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria.

Bachelors degree in Nursing preferred. Currently licensed to practice nursing in North Carolina. Minimum five (5) years clinical experience required. Coding skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic preferred.

Employment Type

Full Time: 36 or more hrs/wk