Clinical Documentation Specialist

IT'S SIMPLE. You want to work in a hospital setting where you are valued and appreciated - where you receive respect from your superiors and co-workers as well as the patients you treat.

You want to be challenged by your job without being overwhelmed by it.  You want to play an instrumental role in helping a patient recover, sometimes against strong odds, and go home. What you want is Kindred Healthcare.

Our mission is to promote healing, provide hope, preserve dignity, and produce value for each patient, resident, family member, customer, employee, and shareholder we serve.  Join us!

Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.

Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Integrity Specialist (CDIS), will strive to ensure comprehensive medical record documentation that reflects patients’ clinical treatment, decisions, and diagnosis. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. This position will actively participate in educating appropriate hospital and medical staff about ICD-10.

ESSENTIAL FUNCTIONS
• Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures
ensuring accuracy of medical record documentation to support maximum reimbursement.
• Concurrently abstract information from the medical record in accordance with the conventions and rules associated with the International Coding Classification of Diseases and Operations
• Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed, and queries left in the medical record have been answered by the provider.

• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes.
• Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise, and Hospitals policy
• Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting
• Conducts educational sessions with physicians and other health care team members on documentation requirements
• Reviews clinical issues and identified query response concerns with hospital leadership, physician advisors or designee.
• Identifies and reviews principal and secondary diagnoses and complications to ensure diagnosis specificity. Also identifies and reviews for POA (Present on Admission), Hospital Acquired Conditions (HACs) documentation and initiates a communication clarification process when appropriate with providers.
• Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation.
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10
• Participates in department and facility Quality and Performance initiative
• Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Director of Quality, Medical Staff Credentialing, and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement.
• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance, and coding staff.
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
• Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees.
• Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff
• Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health
• Collaborates, coordinates, and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding
• Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities
• Attends meetings as required and participates on committees and teams as directed

Minimum Education
Associate or bachelor’s degree from an accredited school of nursing, Health Information Management, and/or
medicine or healthcare undergraduate/graduate degree. Master’s Degree is preferred but not required.
Minimum Work Experience
1. 3-4 years clinical experience (i.e., inpatient, clinical documentation, and/or case management reviews). Prior
Clinical Documentation Improvement experience preferred. Certified Clinical Documentation Improvement
Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner or completion within two years of
employment.
2. Knowledge of concurrent coding and documentation improvement, preferred.
3. Experience in development of reference based continuing educational programs using Adult Learning
Principles. Must be self-motivated and could work within the established policies, procedures and
practices prescribed by the facility, corporation, and the immediate supervisor.