Steward Health Care System
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Clinical Documentation Specialist I
at Steward Health Care System
Provide clinically based concurrent review of inpatient medical records to access and procure accurate and complete documentation of the patient's diagnoses and procedures. The goal of concurrent review is to facilitate clinically appropriate physician/clinical documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness and risk of mortality to support correct coding, and quality initiatives.
- Analyze clinical information to identify areas within the chart for potential gaps in physician documentation, formulate credible clinical documentation clarification to improve documentation of principal diagnosis and co-morbidities present upon admission.
- Identify strategies through data gathering and analysis of trends to establish recommendations for sustained work process changes that facilitate complete, accurate, clinical documentation to support correct coding and DRG assignment through extensive interaction with providers and HIM coding professionals.
- Queries physicians and other caregivers as necessary via approved written communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk mortality.
- Performs monthly closed chart reviews and serves on the Utilization Review Committee.
- Serves as a resource for physicians to help link ICD-9-CM and/or ICD-10-CM/ PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment.
- RN with relevant clinical experience
- Graduate of an approved Health Information Technology/Management with credentials of RHIA, RHIT, RHIA/RHIT eligible, CCS, CCS-P, CCS/CCS-P eligible preferred
- Demonstrated knowledge of ICD-9-CM, ICD-10-CM MSDRGs, documentation compliance standards and coding principles/guidelines preferred
- 2-3 years previous experience preferred
- Must show ability to communicate effectively and diplomatically within a multi-functional team, including physicians, HIM coders, and other members of the allied health care team.
- Must possess strong organizational skills and attention to detail.
- Computer skills required.