Sr. Clinical Documentation Specialist (RN required)

Sr. Clinical Documentation Specialist (RN required)

JOB SUMMARY:
Ensures capture of discharge diagnosis and procedures independently. Documents the patient's clinical status and care provided. Performs concurrent review of patient records for documentation to support assignment of clinical codes.

• RN licensure (required)
• A minimum of 3 years of CDI experience (preferred)
• Clinical Documentation Specialist certification ( ACDIS) preferred
• Proficient with the use of Microsoft products( Excel, WORD, PowerPoint, Outlook) preferred
• Previous working experience with Epic systems preferred

KEY RESPONSIBILITIES:

• Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness.
• Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete.
• Communicates with providers regarding missing, unclear, or conflicting clinical documentation.
• Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge.
• Monitors provider documentation queries for timely and compliant response and escalates issues.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES:

WRITTEN COMMUNICATION (NOVICE): - Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.

MEDICAL CODING (INTERMEDIATE): - The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.

VERBAL COMMUNICATION (NOVICE): - Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.

CRITICAL THINKING (NOVICE): - The objective analysis and evaluation of an issue in order to form a judgment.

CORE ACCOUNTABILITIES:

• Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
• Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
• Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
• Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.