RN - Registered Nurse Clinical Documentation Improvement Specialist Senior (CCDS Certification Required)

Job Summary

The Clinical Documentation Improvement Program is designed to improve the physician’s documentation in the patient’s medical record supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Assists the providers with accurately identifying and documenting the healthcare services provided to the patient. Analyzes the clinical information, using the documentation as the primary driver. Acts as documentation liaison to physician staff as a means of finalizing information in the medical record.

Job Duties

• Reviews inpatient medical records within twenty four to fourty eight hours of admission for a specified patient population toevaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate assignment, risk of mortality, severity of illness; and initiate documentation of the review.
• Pursues a subsequent review of records every three days to support and assign a working DRG assignment upon discharge.
• Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
• Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
• Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
• Consistently meets established productivity targets for record review.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
• Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
• Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.
• Assists with the establishment of training tools for all staff and other employees in regard to quality documentation and coding improvement and further communicates the ongoing improvements relative to process automation, streamline and employee development.
• Participates in the training of all new staff, including on-going mentorship.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.