Clinical Documentation Specialist RN - REMOTE

Position Purpose

The purpose of this position is to evaluate and establish the appropriateness of the Working DRG (working diagnosis related groups) or HHRG (home health related groups) assignment relative to the existing clinical documentation within the medical record provided by the health care provider. The clinician will identify potential Working DRG/HHRG assignment based on documentation and clinical indicators to improve the quality of documentation ensuring compliance established by State and Federal Regulations. Clinicians will also provide education to and collaborate extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.

Working DRG reviews are done by incumbent(s) housed in 200734

Nature and Scope

The Clinical Documentation Integrity Specialist (CDIS) serves as a resource to the physician and other providers to produce clear and precise clinical documentation in the medical record to achieve the most accurate, concurrent, compliant documentation of diagnoses, severity of illness, risk of mortality and complexity of patient care.

The clinician must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for Working DRG. The clinician must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded.

The clinician must be a professional, team player, able to communicate well with others. The clinician must have strong interpersonal skills, pleasing personality and maintain a positive attitude. The clinician will have regular significant contacts with other personnel throughout and outside the medical center. These contacts may be in person, by telephone, or through correspondence

This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in treatment modes and new procedures, and to clarify diagnoses when physician documentation is vague or missing.

This position does not provide patient care.

Minimum Qualifications
Requirements - Required and/or Preferred