Clinical Documentation Specialist II - Revenue Cycle

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After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile.

Thank you,Human Resources## Important Applications Instructions:
** Please complete this application in entirety by providing all of your work experience, education and certifications/
**** license.  You will be unable to edit/add/change your application once it is submitted.**## Job

Requisition :

R## Job Category:

Nursing## Organization:

Rev Cycle - HIM CDI## Location/s:

Central Billing Office-Clinton##

Job Title:

Clinical Documentation Specialist II - Revenue Cycle##

Job Summary:

To support and review the inpatient medical record in order to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG based or APR based payor population for specific departments or areas. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.## Education & Experience Five (5) years of clinical nursing in Acute Care, Utilization Review, Case Management, Quality Management and/or Hospital-based Clinical Documentation experience.
Hospital based Clinical Documentation experience preferred.

** Certifications, licenses or registration required:
** Valid RN license. CCDS (Certified Clinical Documentation Specialist) preferred upon hire, but is required within three years of hire.## Knowledge, Skills & Abilities
* Knowledge of evidence-based clinical guidelines across a wide variety of conditions and age groups. Knowledge of resource/utilization management. Skill in the use of personal computers and related software applications. Ability to manage multiple priorities under time constraints; ability to analyze and solve problems.
* Understanding of cost and quality issues. Excellent verbal and written communication skills.  Interpersonal skills to interact with a wide range of constituencies. Decision-making skills.
* Demonstrated ability to perform and maintain working relationships within the department and across all business units to foster a team environment. Effective written and verbal communication skills required. Healthcare revenue cycle experience preferred.
* Proficient knowledge and experience in Microsoft office Suite (Excel, PowerPoint, Word & Outlook).
* ** Responsibilities:
*** Reviews inpatient medical record within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption.  Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Identifies
* Present on admission diagnoses. Identifies quality issues and reports to the responsible party.  Is proficient in more complex decision-making with high degree of accuracy.
* Reviews and enters information in both epic and 3m 360 as required.  Proficient in using these software systems.
* Ensures accuracy by reviewing inpatient charts every 24-48 hours as a follow-up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software.  Proficient in quality and production.
* Communicates with physicians and other patient care providers, both verbally and written in a clear and concise way, regarding documentation opportunities for improvement.  Assists in development and presentation of educational materials regarding documentation to both cdi staff and/or providers and other members of the healthcare team.
* Proficient effective assessment skills to identify clinical indicators for diagnoses.  Integrates new or current techniques (of procedures or surgery, cdi issues, opportunities for documentation improvement) to obtain information as it relates to the planning, implementing, and evaluating of patient care documentation.
* Provides timely internal/external customer service in a cooperative, professional, and respectful manner.
* Ability to formulate a more complex query in order to  obtain clarifications of conflicting, ambiguous, or non-specific documentation, by verbal or written compliant queries.  Ability to determine when it is appropriate to escalate an issue to senior team member, provider, or administrator.
* Collaborates with CDI Specialist III to review individual problematic cases and/or educational needs.
* Has a highly developed understanding of what constitutes a risk management and/or quality program (PSI/HAC) case, and discusses with senior team member, as appropriate.
* Must maintain a current ACDIS…