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Clinical Documentation Specialist

Washington, DC
The Clinical Documentation Specialist (CDS) collaborates extensively with physicians, nursing staff and other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
Interacts with Physicians, Nursing staff, Other Patient Caregivers, Patient Access, Patient Accounts, Nursing, Information Systems, and Ancillary Departments.
Performs daily concurrent review of records on assigned nursing unit to identify opportunities to obtain accurate documentation and reflect severity of illness.
Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid, Blue Cross, etc.) (This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged.) The CDS will  also  perform  focused  reviews at the discretion  of the HIM Director or the Chief Medical Officer.
Conducts retrospective reviews of discharged records for accuracy of final DRG assignment consistent with clinical documentation.
Educates all members of the patient care team on an ongoing basis.
Assigns a working DRG using Cooperating Parties coding guidelines and Physician Query Tracking software or other developed methods.
Verifies presence of clinical documentation supporting patient's severity of illness equating to intensity of service.
Assures presence of continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress" of the patient.

Facilitates completion of discharge summaries in promotion of post-acute care to facilitate orderly handoff to patient's primary care physician.
Queries physicians on a concurrent basis to ensure accurate documentation is recorded in the medical record.
Follows-up on physician queries to ensure appropriate documentation is recorded in the medical record prior to coding and billing.
Works with Coding staff to clarify documentation, ensuring that the most accurate DRG has been assigned for billing purposes.
Identifies missed opportunities related to clinical documentation and coding guidelines.
Follows up with required documentation that results in the accurate capture of the severity and/or mortality indices.
Keeps daily production of cases reviewed and queried, using the Physician Query Tracking software.
Enters physician responses using the Physician Query Tracking software for monitoring of trends, training opportunities, compliance, and response time.
Assists in the education of physicians and clinicians regarding the importance of Clinical Documentation Improvement (CDI).
Refers quality issues to the Director of CDI/HIM. Participates in departmental quality assurance activities.

Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of

Ethics and the Health Sciences Standards of Conduct.
Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
Participates in activities that promote adherence to federal healthcare program requirements. Actively participates in Health Sciences Compliance Program activities.

Adheres to the requirements of the HIPAA Privacy Policies and Procedures. Maintains confidentiality of patients, families, and staff.

Assumes other duties and responsibilities that are related and appropriate to the position and area.

The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
Ability to analyze and understand complex data and computer system related to the master patient index and forms document management.
Excellent problem-solving skills, including the ability to interpret system processes and reports. Highly developed judgment skills in establishing priorities and managing time.

Ability to independently operate hardware and software systems. Demonstrated usage of spreadsheets, presentation software, databases, and word-processing.
Demonstrates excellent written and verbal communication and presentation skills. Professional-level initiative and orientation towards work responsibilities.

Must be able to work independently and prioritize  multiple  tasks and  priorities. Knowledge of professional practice standards regarding Health Information Management. Extensive knowledge of medical terminology, anatomy and physiology.

Strong working knowledge of Microsoft Office Suite applications. Knowledge of basic Education and

Training principles of the adult learner. Knowledge of healthcare environment.

Ability to analyze complex data.
Ability to maintain confidentiality in all aspects of the Hospital's business.
Ability to participate in Process Improvement (PI) activities and make recommendations for improving quality of Health Information Management service.
Ability to work flexible hours as dictated by the needs of the project and department needs. Ability to meet schedules and inflexible timelines.
Ability to work with a minimum of direction.
Knowledge of medical coding and reimbursement methodologies.
Ability to learn and apply current coding guidelines and reimbursement methodologies. Competence in both oral and written English
Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public.
Must demonstrate collaboration; accountability; respect; excellence; and service.
Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors; looks for ways to achieve departmental/institutional results by partnering.
Accepts responsibility for his/her actions to provide health care and or ancillary functions in a highly efficient and compassionate manner. The employee must function as a Steward (Have Ownership) of the Howard values that foster a commitment to improving the patient and student experience , organizational efficiency and the environment.
Embraces diversity; cares holistically for those we serve; treats all as we would like to be treated; manages the patient's right to privacy with meticulous care 100% of the time and keeps patient and proprietary information about the institution confidential.
Anticipates the patient's and student's needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our customers.
Behaves in a friendly, resourceful and professional manner towards all they encounter; treats patients, students and visitors in the same way that they would want their family members or themselves to be treated.
Health Information Professionals:
  • Graduate of an accredited Health Information Management Program with credentials of a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
  • Four (4) years of recent working experience with ICD-9-CM and/or ICD-10 Inpatient Coding/ORO assignment highly recommended.
  • Minimum of one (1) year recent experience as inpatient CDS in acute care hospital highly recommended.
  • One or more of the following professional certifications in medical coding or clinical documentation improvement desirable:
    • Certified Coding Specialist (CCS) (from AHIMA)
    • Certified Clinical Documentation Specialist (CCDS) (from ACDIS)
    • Clinical Documentation Improvement Practitioner (CDIP) (from AHIMA) .
Nursing Professionals:
  • Graduate from an accredited school of Nursing; Registered Nurse, BSN preferred.
  • Minimum of five (5) years of direct clinical nursing experience.
  • Minimum of one (1) year experience as inpatient CDS in acute care hospital highly recommended.
  • Utilization Review or Case Management experience preferred.
  • One or more of the following professional certifications in medical coding or clinical documentation improvement desirable:
    • Certified Coding Specialist (CCS) (from AHIMA)
    • Certified Clinical Documentation Specialist (CCDS) (from ACDIS)
    • Clinical Documentation Improvement Practitioner (CDIP) (from AHIMA)
Medical School Graduates:
  • Graduate of an accredited Medical School with minimum 4 years of medical science education.
  • Minimum of one (1) year experience as inpatient CDS in acute care hospital highly recommended.
  • One or more of the following professional certifications /diploma in medical coding or clinical documentation improvement desirable:
    • Diploma in medical coding
    • Certification in medical coding (CCS from AHIMA)
    • CDIS (from ACDIS) or CDIP (from AHIMA)
Professional, team player, able to communicate well wit/z others. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside the hospital. Contacts may be in person, by telephone, or through correspondence.
Good critical thinking skills, able to assess, evaluate, and teach. Flexible with a working knowledge of all areas of medicine.
Must be able to stand, walk, sit, lift, climb, stoop, kneel, crouch, crawl,  bend,  pull, push, reach,  write, type, file, speak, hear, see (depth perception, color vision), calculate, compare, edit, evaluate, interpret and organize for extended periods of time.
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