Clinical Documentation Specialist
Facility: Valleywise Health Medical Center
Department: Health Information Management
Schedule: Regular FT 40 Hours Per Week
Under the direction of the Clinical Documentation Improvement Supervisor, the Clinical Documentation Specialist uses clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation of patient records on a concurrent basis using a multidisciplinary team process. Works collaboratively with physicians to ensure clinical information in the medical record is present and accurate. This position collaborates with Coding to support the appropriate severity of illness and risk of mortality. The Clinical Documentation Specialist (CDS) will interact with physicians and ancillary staff providing education regarding documentation clarification. Works in collaboration with hospital departments to support efforts that justify medical necessity, admission, continuity of patient care and other clinical documentation requirements.
- Requires an Associate's degree in Nursing or Health Information Technology or related field; or an equivalent combination of training and progressively responsible experience that will result in the required specialized knowledge and abilities to perform the assigned work. A Bachelor's degree in Nursing or Health Information Administration or related field is preferred.
- Must have a minimum of three (3) years of recent clinical nursing, coding, or clinical documentation experience that demonstrates an understanding of the required knowledge, skills and abilities.
- Clinical documentation improvement specialist experience or training is preferred.
- Must possess a current, valid AZ RN or LPN license or valid compact RN or LPN licensure for current state of practice; or must possess a certification as a RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.
- A Certified Clinical Documentation Specialist (CCDS) certification must be obtained within thirty (30) months of hire.
Knowledge, Skills & Abilities:
- Requires exceptional critical thinking, communication skills and a strong clinical knowledge base.
- Must possess effective interpersonal skills in order to interact effectively with Providers.
- Requires analytical skills to interpret medical record documentation and formulate appropriate Provider queries based on need for increased documentation specificity to clarify, link or establish diagnoses, conditions and procedures.
- Must possess knowledge of a wide range of specialized disciplines, including a strong knowledge base in anatomy and physiology, pathophysiology, and pharmacology; and knowledge of the AHA Coding Clinic and AHIMA Query Practice Brief guidelines.
- Requires the ability to benchmark and analyze clinical documentation program performance.
- Must have knowledge of MS and APR-DRG's, DRG assurance, Coding, Revenue Cycle, and Midas.
- Requires basic computer word processing skills (e.g. formatting, editing, printing, composing email, internet searches, etc.) to be able to successfully navigate through an electronic medical record using a computer.
- Requires the ability to read, write and speak effectively in English.