Senior Clinical Documentation Specialist (RN Required) - REMOTE

JOB SUMMARY:

Under direction, responsible for daily CDE work flow analysis and coordination of program resources. With support, ensure that the appropriate infrastructure is in place to support, maintain and achieve overall documentation excellence and compliance to support accurate program metrics and appropriate reimbursement. Works with physicians and staff to promote best documentation practices to ensure capture of discharge diagnosis(es), including any co-existing co-morbidities, and procedures in order to accurately reflect the patient's clinical status and care provided. Performs concurrent review of patient records for optimum documentation to support accurate assignment.

REQUIREMENTS:

• A minimum of 3 years working as a Clinical Documentation Specialist
• Registered Nurse Required
• Excellent written and oral communication skills
• Strong understanding of inpatient coding and reimbursement
• Proficient with Microsoft Office Suite of Applications especially Excel, Word, and PowerPoint
• Experience with 3M 360 preferred
• Epic Medical Record System experience required
• Clinical Documentation Specialist certification (ACDIS) preferred.
• Proficient with the use of Microsoft products (Excel, WORD, PowerPoint, Outlook) required.

KEY RESPONSIBILITIES:

• Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness as they relate to assignment of codes, MS-DRGs and APR-DRGs.
• Supports QSRP and external reporting initiatives through concurrent review of medical record documentation
• Works closely with coding staff to ensure documentation of discharge diagnoses and procedures are complete.
• Communicates with physicians regarding missing, unclear, or conflicting clinical documentation.
• Collaborates with case managers, nursing staff, and other ancillary staff.
• Monitors provider documentation queries for timely and compliant response and escalates issues.

TECHNICAL CAPABILITIES:

MEDICAL CODING (INTERMEDIATE): - The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. ICD- 10- CM and PCS coding skills.
MEDICAL TERMINOLOGY & DOCUMENTATION (ADVANCED):- The ability to comprehend medical terminology, anatomy & physiology, and pharmacology treatments in an inpatient hospital setting.
CRITICAL THINKING (ADVANCED):- The objective analysis and evaluation of an issue in order to form a judgment.
COMPLIANCE (ADVANCED):- Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.
VERBAL COMMUNICATION (ADVANCED):- Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.
WRITTEN COMMUNICATION (ADVANCED): - Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos, and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.
PEER LEADERSHIP (INTERMEDIATE): - The ability to show leadership and influence people of equal rank to accomplish team goals.

CORE ACCOUNTABILITIES:

• Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in.
• Problem Solving/Complexity of Work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others.
• Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas.
• Team Interaction: May lead mid-sized projects; coaches and guides team members.

Graduate of an approved discipline specific program (or equivalent experience) and 3 years relevant experience

NOTE: 5 years of relevant experience preferred

Licensure, Certification, and/or Registration (LCR):

• Registered Nurse Required

Additional Qualification Information:

• Industry certification in clinical documentation improvement (e.g., CDIP, CCDS) preferred.

Physical Requirements/Strengths needed & Physical Demands:

• Sedentary category requiring exertion up to 10 lbs. of force occasionally and uses negligible amounts of force to move objects. Sedentary work involves sitting most of the time.

Movement

• Occasional: Standing: Remaining on one's feet without moving.
• Occasional: Walking: Moving about on foot.
• Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another
• Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.
• Occasional: Push/Pull: Exerting force to move objects away from or toward.
• Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles
• Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.
• Occasional: Reaching below shoulders: Extending arms in any direction below shoulders.
• Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.
• Occasional: Bimanual Dexterity: Requiring the use of both hands.
• Occasional: Standing: Remaining on one's feet without moving.
• Occasional: Walking: Moving about on foot.
• Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another
• Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.
• Occasional: Push/Pull: Exerting force to move objects away from or toward.
• Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles
• Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.
• Occasional: Reaching below shoulders: Extending arms in any direction below shoulders.
• Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.
• Frequent: Sitting: Remaining in seated position
• Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.
• Frequent: Sitting: Remaining in seated position
• Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.

Sensory

• Continuous: Communication: Expressing or exchanging written/verbal/electronic information.
• Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information
• Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.
• Continuous: Communication: Expressing or exchanging written/verbal/electronic information.
• Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information
• Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.