Clinical Documentation Specialist

UNC HEALTH
Published
August 4, 2022
Location
United States
Category
Other  
Job Type
Work Setting
In-office

Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary

The Clinical Documentation Specialist will be responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist will be responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. This position will report to the Health Care System Supervisor of Clinical Documentation Integrity.

Responsibilities

  • Perform concurrent inpatient reviews and facilitates appropriate clinical documentation to support the severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and complexity of care rendered to all patients. Perform outpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients.
  • Accurately assign the working MS-DRG, ICD-10-CM codes, ICD-10-PCS codes, CPT Codes, and HCPCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non-clinical staff to expedite the resolution of documentation clarification queries.
  • Provide effective education using tools and during rounds and meetings (as required). Support the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourage open dialogue. Respond to questions, concerns, and requests promptly.
  • Compliantly follow workflow processes and competently utilize software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.
  • Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.

Other Information

Education Requirements

  • Associate's degree in Health Information Management, Nursing or related field.
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.

Licensure/Certification Requirements

  • Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license

Professional Experience Requirements

  • Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care experience

Knowledge/Skills/and Abilities Requirements

  • Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making.
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