CLINICAL DOCUMENTATION SPECIALIST (On-Site)

Description

At Gila Regional Medical Center, the Clinical Documentation Specialist position is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG's, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This Clinical Documentation Specialist position also facilitates modifications to clinical documentation through extensive 

interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties for this position include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis. Primarily responsible for conducting post-service in-depth clinical reviews (all care settings) in accordance with accepted standards of care. The overall goal is to improve clinical service delivery.

Requirements

ESSENTIAL FUNCTIONS:

• Demonstrates knowledge of ICD10 and CPT payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
• Demonstrates accountability and professional development
• Excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Regular significant contacts with other personnel throughout the institution (including but not limited to physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence
• Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others
• Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary.
• Tracks responses and trends completion of E&M/DRG/Documentation worksheets as pertinent to scope of department.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
• Helps identify appropriate CPT/HCPCS codes for procedures related to projects or studies being conducted as needed
• Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies.
• Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information
• Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines.
• Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
• Follows all HIPAA, Federal, and State Confidentiality, Privacy and Security Laws.
• Additional duties as assigned.

EDUCATION & TRAINING REQUIREMENTS:

• Associates or Bachelor degree preferred
• CCDS - Clinical Documentation Specialists (ACDIS) or
• CDIP - Certified Documentation Integrity Practitioner (AHIMA) or
• CCS - Certified Coding Specialist (AHIMA)
• Certification must obtained within 1 year after the hire date
• Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
• Managed Care/Medicare Advantage experience required
• Proficient in ICD10/CPT/HCPCS codes