Associate Clinical Documentation Specialist (RN)

Yale New Haven Health; New Haven (CT); On-site; USD 85,000 - 120,000; Full time

Job summary

Yale New Haven Health in New Haven, CT is seeking an Associate of Clinical Documentation Specialist to facilitate modifications to clinical documentation through real-time clinician interactions, ensuring accurate DRG and appropriate coding. The role requires an active RN license, BSN preferred, and at least three years of inpatient acute care experience; ICU experience is a plus.

You will collaborate with CDS and coding staff, maintain high audit scores, and contribute to quality measures

Qualifications

• Active RN license required.
• BSN preferred.

Responsibilities

• Review medical records to identify principal and secondary diagnoses, procedures, and assign a working DRG.
• Concurrently and retrospectively review charts to ensure DRG reflects diagnoses and comorbid conditions.
• Collaborate with coding staff to ensure documentation supports accurate coding.
• Develop strong professional relationships with CDS, Coding staff, physician leadership and clinicians.
• Use compliant query processes and document follow-up until closure.

Skills

Communication

Negotiation

Organizational skills

Adaptability

Data extraction

Willingness to learn

Third-party systems

Computer literacy

Software platforms

Collaboration

Independence

Flexibility

Detail-oriented

Education

RN license

BSN preferred

Tools

Electronic Health Records

Job description

Overview

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 Associate of Clinical Documentation Specialist (CDS) will facilitate modifications to clinical documentation, through extensive real time 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 integrity, quality and completeness.

EEO/AA/Disability/Veteran

Responsibilities

• Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis, secondary diagnoses, procedures, 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.
• Completes reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
• Collaborate with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
• Develops and supports strong professional relationships with CDS, Coding staff, Physician Leadership and clinicians across the system.
• Utilizes a compliant query process per guidelines and policy when sending all queries. Follows each query through to closure including complete documentation of ongoing follow up activities and communication
• Works collaboratively with all licensed independent providers to ensure positive program outcomes
• Provides ongoing CDS team learning opportunities by sharing professional knowledge
• Maintains integrity and compliance in all chart reviews, CDI documentation and queries at all times
• Supports and implements quality measures as identified by department management
• Maintains an audit score > 95%
• Identify and implement opportunities for performance improvement

Qualifications

EDUCATION

• Registered Nurse with active RN license required. Bachelors of Science in Nursing preferred.

EXPERIENCE

• A Minimum of three (3) years of recent in-patient acute care nursing experience required. Recent ICU experience preferred. Clinical expertise required.

LICENSURE

• RN license required.

SPECIAL SKILLS

• 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 records to extract data.
• Demonstrate Willingness to learn clinical and coding concepts.
• Exhibits working knowledge of third party and prospective payment systems.
• Computer literacy required.
• Ability to work on various software platforms.
• Must be capable of working collaboratively and independently.
• Must display flexibility with responsibilities to meet departmental needs.
• Must have keen eye to detail.

PHYSICAL DEMAND

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