Clin Documentation Spec I (RN)

New Haven, CT
Apr 23, 2019


Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.


The Clinical Documentation Specialist I RN will facilitate modifications to clinical documentation, through extensive concurrent interactions with physicians and other clinicians in order to reflect appropriate clinical severity, complications and co-morbidity. The specialist shall concurrently review and evaluate selected patient's medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.

  • 1. Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and to assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
  • 1.1. Completes the initial review within 24-48 hours of admission.
  • 1.2. Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
  • 1.3. Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
  • 2. Educates internal staff on clinical documentation and coding guidelines. Develops and conducts ongoing CDMP education for new staff including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals.
  • 3. Develops and supports strong professional relationships with CDS, Coding staff, Physician Advisors and medical providers across the system.
  • 4. Utilizes a compliant query process per guidelines and policy when conducting all queries. Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
  • 5. Works collaboratively with Physician Advisors to ensure positive program outcomes.
  • 6. Provides in person CDI training to providers one on one, during staff meetings or department meetings.
  • 7. Assists in other monitoring activities, special department projects or other needs as determined by the department manager.
  • 8. Provides ongoing CDS team learning opportunities through sharing of professional knowledge.
  • 9. Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
  • 10. Supports and implements quality measures as identified by department manager.
  • 11. Identifies opportunities for performance improvement.
  • 11.1. Supports and implements PI measures identified.
  • 11.2. Monitors and triages CDI review opportunities for identified cluster DRGs to ensure the documentation is complete and accurate.

    Other information:

    Registered Nurse with active license , BSN preferred. CCS preferred.

    At least three (3) years of recent acute care nursing experience required . ICU experience preferred. Clinical expertise required .

    RN license required . CCS preferred.

    Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in use of medical record to extract data. Working knowledge of third party and prospective payment systems. Computer PC literacy required. Must be able to work collaboratively and independently. Must be flexible with responsibilities in order to meet departmental needs. Must have keen eye to detail.

    Responsible for facilitating the capture of documentation to support the severity of illness and resource consumption associated with the care of specific patients on a concurrent basis. Collaborates with physicians, care coordinators, medical records and coding departments as necessary. Must be conscious of quality of documentation issues and bring issues and possible solutions to the issue to the attention of the appropriate department or person in timely manner or person in timely manner.

    Exercises independent judgment and tact in dealing with physicians, patients, families, and other hospital personnel. Serves as a resource for members of the Care Management team. Participates in the orientation of new staff.

    Ability to communicate clearly and confidently to providers the program goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication.

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    Job Info

    Job: 7131

    Department: Clinical Documentation Improve
    Category: Him/med Records
    Status: Full Time
    Shift: DAYS
    Hours: 40.00

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