Description

Must live in MS, AL, LA, FL, TX, GA or NC. 

Position Overview
The Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients. He/She analyzes the clinical status of patients, current treatment plans and past medical history to identify potential gaps in clinical documentation. The Clinical Documentation Specialist educates and serves as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding. He/She reconciles DRG differences between the Coding staff and Clinical Documentation Specialist; and monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations. 

Requirements

Education:
High School graduate or equivalent required.

If Registered Nurse, must be a graduate from NLN School or Nursing; Bachelor of Science in Nursing required.

License:
If Registered Nurse (RN), must hold current applicable license to practice in Mississippi.

Certifications:
If not a Registered Nurse, must be certified by the American Health Information Management 
Association (AHIMA) or American Academy of Professional Coders (AAPC) as a:
Registered Health Information Administrator
Registered Health Information Technician
Certified Code Specialist
Certified Inpatient Coder
Must complete all requirements (including continuing education) to maintain certification.
CCDS preferred.

Must have de-escalation training completed by the end of position orientation (90 days); must have appropriate level of de-escalation training.  

Experience:
A Registered Nurse must have a minimum of two (2) years’ nursing experience in an acute-care facility. 

Coders must have a minimum of two (2) years’ experience in ICD-9 CM and experience utilizing ICD-10 CM and ICD-10 PCS in an inpatient setting. Must have working knowledge of the AHA Coding Clinic.

An understanding of the MS-DRG payment system is required. An understanding of APR-DRG’s preferred.

Reports to:
Clinical Documentation Manager

Supervises:
None

Physical Demands:
Work is moderately active: involves sitting with frequent requirements to move about the office, move about the facility, and to travel to another facility within the SRHS service area. Work involves exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.

Work involves using many physical motions in performing daily work activities; subject to exposure of body fluids, sputum and tissues, which may carry the hazard of infectious disease. Work involves using repetitive motions: substantial movements of the wrists, hands, and or fingers while operating standard office equipment such as computer keyboard.

Work involves being able to perceive the nature of sound at normal speaking levels with or without correction; the ability to make fine discriminations in sound. Work requires close visual and acuity and the ability to adjust the eye to bring an object into sharp focus, i.e. shift gaze from viewing a computer monitor to forms/printed material that are closer to compare data at close vision.

Must be able to be active for extended periods of time without experiencing undue fatigue. Must be able to work schedules assigned with the understanding that changes may be instituted according to the needs of the hospital for off days, shifts or weekends.

Mental Demands:
Must demonstrate keen mental faculties/assessment and decision making abilities.  Must demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone.  Must demonstrate strong written and verbal communication skills.  Must possess emotional stability conducive to dealing with high stress levels.  Must demonstrate ability to work under pressure and meet deadlines.

Attention to detail and the ability to multi-task in complex situations is required.  Must have the ability to maintain collaborative and respectable working relationships throughout SRHS and other organizations.

Special Demands:
Must possess superior customer service skills and professional etiquette.  Must possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word.

Job requires traveling throughout the SRHS service area – with the employee providing his/her own transportation.

Work requires the ability to function independently, adapt to workload demands, set priorities, and understand and set goals. Must possess highly developed organizational, planning and management writing skills. Must understand the fundamentals of automated data processing, and be able to quickly gain a detailed understanding of complex computerized and non-computerized information.