Clinical Documentation Specialist II Exempt

Schedule

Full time

Shift

Day (United States of America)

Address

1035 RED BUD RD NE

City

CALHOUN

State

Georgia

Postal Code

30701

Job Description

• The Clinical Documentation Specialist II Exempt inputs data into CDI Software accurately and concisely, resulting in precise metrics obtained through the reconciliation process.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.
• Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs to ensure documentation compliance.
• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.
• Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation.
• Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues, presentations for educational opportunities, and other needs identified by CDI leaders.
• Maintains a 98% physician response rate to all valid clarifications.
• Assists in new hire orientation through precepting and mentoring.
• Completion of educational project to be presented to CDI team yearly.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities

• The Clinical Documentation Specialist II Exempt possesses excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required]
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills. [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist. [Required]
• Dependable, self-motivated, and pleasant. [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills. [Required]
• Knowledge of pathophysiology, disease processes, and treatments. [Required]
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures. [Required]
• Coding background. [Required]
• Knowledge of quality guidelines. [Required]

Education

• Associates [Required]

Field of Study

• In Registered Nursing or health related field

Work Experience

• 4+ years of acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 2+ years of clinical documentation specialist [Required]

Additional Information

• Candidate may be an unlicensed physician who graduated from a medical school listed in the World Directory of Medical Schools AND meets eligibility requirements to apply for the ECFMG Certification.

Licenses and Certifications

• Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]
• Certified Clinical Documentation Specialist (CCDS) [Required]

Pay Range

$63,240.14 - $117,622.36