Job Details

The Clinical Documentation Specialist is responsible for assisting in the improvement of the overall quality and completeness of provider-based clinical documentation in the medical record. The Specialist will conduct ongoing, concurrent analyses of clinical information in collaboration with physicians, nursing staff, and other patient caregivers to accurately reflect the severity of illness of the patient as well as the level of services rendered.

Requirements:

• Two-year associate degree or four-year bachelor's degree in nursing.
• Applicable clinical or professional certifications and licenses such as RHIT, RHIA, CCS, CPC, CCDS, CDIP, RN, LPN required.
• Minimum of two years related work experience in an acute care setting.
• Clinical, nursing, Health Information Management, and Clinical Documentation experience preferred.
• Proficiency in a medical record review.

Responsibilities:

• Facilitates appropriate clinical documentation to support correct diagnosis coding and ensure the level of service rendered to all patients is documented.
• Communicates with physicians, nurse practitioners, case managers, coders, and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Assigns a working DRG and severity level using coding rules and guidelines with follow-up reviews as required by length of stay prior to discharge.
• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
• Queries physicians on a concurrent basis, monitors the query response from the physician, documents the physician response in 3M, and closes out the analyst's review if prior to discharge.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators.
• Works with Physician Advisor and CDI Manager to resolve documentation discrepancies and clinical disparities.
• Monitors and track trends in clinical documentation, identifying areas for improvement and ensuring compliance with internal and external standards.
• Any other duties as assigned by Woman's Hospital.

Schedule:

Monday - Friday

8:00 AM - 4:30 PM

Pay Range:

Salary/Exempt

$30.00 - $44.00

A Work Experience with Purpose

Woman's is one of the largest specialty hospitals for women and infants in the United States. We are recognized throughout the country for our innovative programs, and we pride ourselves in surpassing the expectations of those we serve. Providing exceptional patient care and creating exceptional patient experiences are at the center of what we do at Woman's. Our team consistently exceeds state and national benchmarks for patient satisfaction.

Our employees, organizational culture, mission, vision, values, and benefits make Woman's a best place to work. In fact, for the 17th year in a row, Woman's has been recognized as a Best Place to Work by Modern Healthcare - making us the only healthcare organization to earn the distinction every year since the program's inception. We are proud of the level of care our staff provides to our patients and each other.

If you have any questions or would like to connect with one of our recruiters directly, please e-mail ...@womans.org.

We are an equal opportunity employer and value diversity and inclusion at Woman's Hospital. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law.