Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.
Reports to: Director, Health Information Management
Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider. Adheres to chart review productivity standards.Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes. Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy. Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports. Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff. Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans. Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department. Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation. Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics. Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees. **This position has the opportunity to work remotely and offers a Sign-On Bonus