Clinical Documentation Specialist

Overview

The Clinical Documentation Improvement Specialist performs patient record reviews concurrently and retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient.

Additional responsibilities include:

• Presents queries to physicians when needed to clarify ambiguous or incomplete documentation.
• The Clinical Documentation Improvement Specialist validates the assigned working Diagnosis Related Group (DRG) to support the operations of Utilization Review and Care Coordination functions.
• Formulates, interprets, and analyzes data relative to opportunities to improve documentation practices, including impact to Diagnosis Related Group, Risk of Mortality and Severity of Illness.
• Educates physicians and advanced practice professionals on best practice clinical documentation.

• Clinical Documentation Integrity, strong understanding of clinical indicators and their impact on SOI/ROM and documentation specificity.
• Basic working knowledge of ICD-10-CM diagnosis coding.
• Experience with mortality reviews and quality-driven documentation practices.
• Experience collaborating with HIM coding professionals.
• Knowledge of or exposure to Solventum/Oracle is a plus but not required.

Excellent critical thinking and effective communication skills; organized, flexible and able to juggle multiple tasks simultaneously. Ability to educate peers and other clinical professionals. Knowledge of Milliman Criteria or Inter Qual Criteria a bonus.

Demonstrates proactive self-starter activities and initiates opportunities for efficiency and improvement. Proficient in using electronic medical records, MS Office products and other clinical software.

Required:

RN (Registered Nurse) State of Missouri or compact RN license, BLS (Basic Life Support) from AHA (American Heart Association), CCDS (Certified Clinical Documentation Specialist) within 2 years of hire, CDIP (Certified Documentation Improvement Practitioner) within 2 years of hire

Required:

Bachelors - Nursing, Preferred:
Masters - Nursing