Clinical Documentation Specialist Job Description

Job summary 1

Under minimal direction, the Clinical Documentation Specialist will provide concurrent and retrospective review of the medical record, 1:1 provider education, and educate clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflect the condition(s) and treatment(s) of the patient. In addition, ensures that documentation reflects the appropriate DRG assignment or APC and HCC assignment, severity of illness, risk of mortality, and quality measures. Coordinates provider educations, and adheres to industry standards pertaining to compliance.

Duties & Responsibilities 1

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Requirements & Skills 1

Job summary 2

The Clinical Documentation Specialist is responsible for obtaining all necessary clinical and client paperwork required to secure funding of a Speech Generating Device. The role requires consistent communication with Speech Language Pathologists, Clients, Caregivers, and other Professionals. The ideal candidate will have experience with collecting and reviewing medical documentation, customer service, HIPAA (Health Insurance Portability and Accountability), and electronic paperwork filing.

Duties & Responsibilities 2

Requirements & Skills 2

Job summary 3

As our next Clinical Documentation Specialist, you will work under the general direction of the HID CDI/Core Measures Supervisor or Manager, with responsibility for improving the overall quality and completeness of clinical documentation.

Duties & Responsibilities 3

Requirements & Skills 3

Job summary 4

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients.

Duties & Responsibilities 4

Requirements & Skills 4

Job summary 5

We are currently seeking a full time Clinical Documentation Specialist. The incumbent in this position facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk mortality. Obtains accurate and compliant reimbursement for acute care services and reports quality of care outcomes. Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules and regulations. Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately. Directs clinical documentation improvement and data abstraction. Ensures accurate and timely reviews of inpatient records.

Duties & Responsibilities 5

Requirements & Skills 5

Job summary 6

The Clinical Documentation Specialist facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation.

Duties & Responsibilities 6

Requirements & Skills 6

Job summary 7

The Clinical Documentation Specialist performs concurrent inpatient chart reviews for documentation improvement opportunities. Communicates with physicians to facilitated comprehensive medical record documentation to reflect clinical treatment and diagnoses, uses hospital’s CDI software to identify opportunities, evaluates documentation on a day-to-day basis, gathers and analyzes information pertinent to findings and outcomes, arranges formal and informal education sessions for all providers, formulated a DRG and confers with coders to ensure appropriate DRG. This review process assures the quality of the documentation used for patient care, regulatory compliance, and reimbursement.

Duties & Responsibilities 7

Requirements & Skills 7

Job summary 8

The Clinical Documentation Specialist works as a team member within the operation of the ""Clinical Coding Team""; supports medical staff by identification of clinical scenarios through interaction and collaboration with physicians, nursing and other members of the health care team to facilitate valid revenue recovery; reports to and performs other duties as assigned by the Leader Adult Health.

Duties & Responsibilities 8

Requirements & Skills 8

Job summary 9

Clinical documentation sounds a little dry, boring and, frankly, clinical doesn’t it? We can assure you it’s none of those things. In today’s health care world, medical record documentation is a critical component of patient care. The Clinical Documentation Specialist must work with physicians and coding staff to accurately and thoroughly document care. The Clinical Documentation Specialist must also be able to communicate relevant medical knowledge to staff. It’s a job that requires someone with top notch written and verbal communication skills. Are you a strong communicator? Do you have experience with medical documentation? Are you able to juggle daily tasks that include writing, working with a team, ensuring compliance and evaluating records? If so, we need your skills.

Duties & Responsibilities 9

Requirements & Skills 9

Job summary 10

The Clinical Documentation Specialist provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Facilitates appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are determined both internally and by requirements of external regulatory agencies. Plays a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Duties & Responsibilities 10

Requirements & Skills 10

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