Job Description

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Department: Health Information Management

Shift/schedule: Full Time (40 hrs/wk)

GENERAL SUMMARY

Clinical Documentation Specialist works under the supervision of the Health Information Manager. The primary job function of the Clinical Documentation Specialist is to conduct concurrent reviews of medical records to ensure that documentation requirements are met to establish severity of illness, risk of mortality, clinical validation along with optimal reimbursement and compliance. Reviews medical records from a clinical prospective to ensure that each diagnoses is clinically validated and the appropriate DRG is assigned to the case. CDI interacts with providers to ensure the documentation reflects the necessary verbage for compliant coding. Documentation specialists are also responsible to work on e on one with providers to obtain answers to queries and do the necessary education to decrease the need for queries. The reviews also assist in identifying hospital acquired conditions to flag these records for additional review of potential charge credit opportunities.

QUALIFICATIONS

Education:

• High School Diploma or successful completion of an equivalent High School Exam Required
• Graduate of an accredited school of practical nursing with 2 years experience in clinical documentation improvement required, -or-
• Graduate of an accredited school of nursing required, -or-
• 10 years of Clinical Documentation improvement experience required, -or-
• Dual certification of CCS (Certified Coding Specialist) and CCDS (Certified Clinical Documentation Specialist) required

Licensure:

• As specified by health specialty required, if applicable

Experience:

• Three years of progressively related experience preferred
• Clinical documentation improvement experience preferred
• Background in Coding Rules and Guidelines preferred

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

1. Conducts initial and/or secondary reviews concurrently on Medicare admissions to establish clinical validation, severity of illness and optimal reimbursement
2. Initiates queries to providers following CMS guidelines to clarify or validate medical documentation and communicates with providers to establish appropriate documentation in the medical record.
3. Performs other duties as assigned.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.