Clinical Documentation Specialist

Description:

The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and supporting them with feedback to accurately reflect the true clinical picture within the medical record. Provider feedback is conveyed through attending practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation as
needed. In partnering with the coding team, the CDS will be an expert with ICD-10, MS-DRG and APR-DRG assignment.

The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient care givers documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate. An additional goal will be to spend face-to-face time with the providers and quickly help the providers understand their specific documentation trends as illustrated through ICD-10 assignment. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, cranial thinking, ability to work independently while following CMS guidelines, organizational policies, and procedures.

Must Have Skills/Qualifications

• CDIP OR CCDS Certification
• EPIC
• Strong Technical / Computer Skills
• Clinical experience working in ICU, Med Surge, NICU/PICU settings
• 4+ Years of Clinical Nursing Experience