Clinical Documentation Specialist II- Full Time Days

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Facilitate clarification to clinical documentation in the medical record; through extensive concurrent reviews with interactions with physicians, nursing staff, other interdisciplinary team caregivers and health information management coding staff, which supports appropriate acuity, resource utilization, quality, severity of illness/risk of mortality (SOI/ROM) and reimbursement. Ensures that clinical severity captured for the level of service rendered to all patients with a DRG based Payor (i.e., Medicare, Medicaid, Commercial, etc.) is accurate. Supports timely, accurate and completed documentation of clinical information, used for measuring and reporting physician and medical center outcomes. On an ongoing basis, CDS will provide educational requirements on clinical documentation to all members of the interdisciplinary care team, while ensuring compliance with regulatory guidelines be maintained.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Identify the most appropriate principle diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulations

• Facilitate modifications to clinical documentation that support the clinical severity of services, clinical validity rendered to all patients with a DRG base Payor (i.e. Medicare, Medicaid, Commercial, etc.)

• Review coding & clinical issues with coding staff to assign the most appropriate working & final DRG

• Complete follow-up/continued stay & potential retrospective reviews of clinical documentation and updates worksheets/findings at least every 24-48 hours or as indicated

• Conduct follow-up/continued stay reviews of clinical documentation to ensure points of clarification documented in the patient’s chart are met

• Confer with physicians face-to-face, via Epic Secure chat, phone and/or via queries to clarify information in medical record, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity of the patient

• Assist with education for all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies

• Review charts with Senior Lead CDIS and/or CDIS Director if unable to reach an agreement with Clinical Coding Specialists

• Assists other team members to ensure completion of all work assignments

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Associate’s degree in Nursing required

• Bachelor's degree in Nursing preferred

• Medical/Osteopathic Doctorate (MD/OD) or an international qualified physician (IMD/MBBS) preferred

• Nurse candidates must have current Registered Nurse licensure in North Carolina or compact/multi-state license required

Work Experience: 

• Nursing candidates must have 5 years of clinical experience in inpatient hospital setting with 1 year of critical care experience (ED, ICU, etc) required

• Medical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required

• 2 years of ICD-10 CDIS experience required

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Excellent observation skills

• Critical analytical thinking, problem solving skills

• Verbal and written communication skills

• Basic knowledge of computers, Microsoft Windows software products and keyboarding skills

• Ability to communicate with people from various professions and backgrounds with tact and diplomacy

• Ability to remain calm in stressful situations

• Knowledge of DRG Payor issues, documentation opportunities and clinical documentation requirements

• Flexible with changing workload/assignments

• Demonstrate positive teamwork/interpersonal relations with all members of teams (coworkers, supervisors, physicians, nurses, etc)

• Ability to work with highly sensitive information and materials where confidentiality is of the utmost importance

• Remote CDS workers must have and maintain secure space and internet connection

Physical Requirements: 

• Some light carrying, lifting may be required

• Occasional walking required to access all areas of the medical center

• Near visual acuity to proofread hand or type written materials

• Reaching, handling and use of fingers to operate office machinery

• Position may involve skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials

• Must be able to lift 35 pounds

Required Licenses and Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity