Clinical Documentation Specialist responsible for receiving and processing healthcare documentation requests. Analyzing and validating requests while ensuring compliance with regulations and organizational standards.
About the role
- Clinical Documentation Improvement Specialist reviewing inpatient medical records for Atrium Health. Ensuring accurate diagnoses and working with healthcare teams to improve documentation.
Responsibilities
- Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
- Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
- Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
- Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
- Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
- Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
- Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
- Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
- Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies
Requirements
- Registered Nurse applicable state Licensure required
- Bachelor's Degree Required
- Appropriate professional certification required within 3 years of hire date per department protocol
- 5 years of related nursing experience preferred
- Clinical experience within the assigned population
- Extensive knowledge of disease processes and clinical outcomes
- Case Management experience or background helpful
- Strong financial and analytical skills preferred
- Word, Outlook, Excel experience preferred
Benefits
- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
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