Community Health Systems
Clinical Documentation Specialist
Community Health Systems, Naples, Florida, United States, 34120
Clinical Documentation Specialist
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance. Essential functions include: Analyzing inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity. Adhering to corporate recommended CDI workflows and using CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices. Utilizing approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and following up daily on unanswered queries. Conducting follow-up reviews of patient records to identify new documentation opportunities and ensuring accuracy through continuous review. Tracking CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts. Providing education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions. Collaborating closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation. Leading physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions. Monitoring regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed. Creating and submitting accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals. Performing other duties as assigned. Maintaining regular and reliable attendance. Complying with all policies and standards. Qualifications include: Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required Bachelor's Degree in Nursing, Health Information Management, or a related field preferred 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred Experience in physician education or query processes preferred Familiarity with regulatory standards and quality metrics related to clinical documentation preferred Knowledge, skills, and abilities include: Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics. Excellent analytical and problem-solving skills to identify opportunities for documentation improvement. Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact). Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams. Ability to develop and deliver educational programs tailored to clinical and administrative audiences. Strong organizational skills and attention to detail to manage multiple priorities and deadlines. Commitment to maintaining compliance with regulatory standards and corporate policies. Licenses and certifications include: RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or Certified Clinical Documentation Specialist (CCDS) preferred RHIT - Registered Health Information Technician preferred or RHIA - Registered Health Information Administrator preferred CDIP - Clinical Documentation Improvement Professional preferred or Certified Coder-AHIMA or AAPC preferred
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance. Essential functions include: Analyzing inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity. Adhering to corporate recommended CDI workflows and using CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices. Utilizing approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and following up daily on unanswered queries. Conducting follow-up reviews of patient records to identify new documentation opportunities and ensuring accuracy through continuous review. Tracking CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts. Providing education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions. Collaborating closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation. Leading physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions. Monitoring regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed. Creating and submitting accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals. Performing other duties as assigned. Maintaining regular and reliable attendance. Complying with all policies and standards. Qualifications include: Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required Bachelor's Degree in Nursing, Health Information Management, or a related field preferred 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred Experience in physician education or query processes preferred Familiarity with regulatory standards and quality metrics related to clinical documentation preferred Knowledge, skills, and abilities include: Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics. Excellent analytical and problem-solving skills to identify opportunities for documentation improvement. Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact). Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams. Ability to develop and deliver educational programs tailored to clinical and administrative audiences. Strong organizational skills and attention to detail to manage multiple priorities and deadlines. Commitment to maintaining compliance with regulatory standards and corporate policies. Licenses and certifications include: RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or Certified Clinical Documentation Specialist (CCDS) preferred RHIT - Registered Health Information Technician preferred or RHIA - Registered Health Information Administrator preferred CDIP - Clinical Documentation Improvement Professional preferred or Certified Coder-AHIMA or AAPC preferred