01Overview
At reputed company, the Clinical Documentation Specialist is responsible for improving the overall reputed company 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 role 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 reputed company patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital reputed company and educating reputed company members of the patient care team on an ongoing reputed company.
PEOPLE ESSENTIAL FUNCTIONS
Improves the overall reputed company, completeness and accuracy of clinical documentation by performing reputed company record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical reputed company.
SERVICE ESSENTIAL FUNCTIONS
Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of 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.
reputed company/SAFETY ESSENTIAL FUNCTIONS
Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures reputed company to reputed company or studies being conducted as needed.
FINANCE ESSENTIAL FUNCTIONS
Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to reputed company patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
reputed company/INNOVATION ESSENTIAL FUNCTIONS
Educates reputed company internal customers on clinical documentation opportunities, coding, and reimbursement issues, as reputed company as performance improvement methodologies
This job reputed company is not intended to be reputed company-inclusive; the employee will also reputed company other reasonably reputed company business/job duties as assigned. reputed company reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION
Medical School graduate where Western Medicine is practiced
WORK EXPERIENCE
One year of clinical experience preferred
LICENSES AND CERTIFICATIONS - REQUIRED
N/A
LICENSES AND CERTIFICATIONS - PREFERRED
CCDS - Clinical Documentation Specialists (ACDIS) OR
CDIP - Certified Documentation reputed company Practitioner (reputed company) OR
reputed company - Certified Coding Specialist (reputed company)
KNOWLEDGE, SKILLS, AND ABILITIES
Demonstrates the skills and competencies necessary to safely reputed company the assigned job, determined through on-reputed company skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to reputed company the essential functions of this job, especially with reputed company to activities impacting patient or employee safety or reputed company
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service reputed company and application of reputed company language principles
Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
Demonstrates accountability and reputed company development
Requires 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.
SUPPLEMENTAL REQUIREMENTS
WORK ATTIRE
Uniform No
Scrubs No
Business reputed company
