Clinical Documentation Specialist II

Inspire health. Serve with compassion. Be the difference.

Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of clinical documentation. This is accomplished by medical record review, query process, and reconciliation process. Participates in the development and delivery of clinical documentation education for providers and health care team members as needed. Serves as preceptor, education resource and second level reviewer for documentation and query justification.

May be called on to validate query impact for team.

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation. (50%)
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (15%)
• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification. (10%)
• Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Fulfils all other duties and responsibilities of a CDIS I (5%)

This is a non-management job that will report to a supervisor, manager, director or executive.

Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.

• Four (4) Adult medical/surgical/critical care/ER/PACU nursing coding or related field
• Clinical documentation improvement experience (2 years)

• One of the following certifications: RN, RHIA, RHIT, CCS, or CIC
• CCDS/CDIP

• Computer skills, keyboarding.
• Strong communication skills with ability to interact with providers and remain tactful.
• General knowledge of IPPS, ICD
  10 Coding, MS-DRG/APR-DRG and HCPCS coding systems.

Day (United States of America)

Corporate

7001 Corporate

Clinical Documentation Integrity

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