Clincal Documentation Specialist (CDS)

Aurora Health Care; Burlington (WI); On-site; USD 65,000 - 85,000; Full time

Job summary

Aurora Health Care is seeking a Clinical Documentation Specialist to lead initial concurrent reviews and collaborate with physicians, nurses, and medical records coders to accurately identify diagnoses, procedures, and DRGs.

The role emphasizes clarifying documentation through queries, educating staff on documentation requirements, and ensuring provider and staff adherence to clinical documentation standards. Strong analytical and communication skills are essential.

Qualifications

• Associate's degree in nursing and RN licensure.
• 3 years of acute inpatient experience.
• Ability to document criteria and communicate with physicians.

Responsibilities

• Perform initial concurrent review to identify indicators.
• Document diagnoses, procedures, and DRG with physician input.
• Clarify documentation via queries to support severity of illness.
• Educate staff on clinical documentation requirements.
• Foster professional relationships to facilitate problem solving.
• Review charts for comorbidities and documentation.
• Monitor progress of the Clinical Documentation Assurance Program.
• Identify quality variances suitable for abstraction.
• Provide information to physicians and staff not responding to queries.

Skills

Clinical docs

Interpersonal skills

Analytical thinking

Query process

Medicare knowledge

Documentation systems

Physician collaboration

Education

Associate's Degree in Nursing

Job description

Major Responsibilities

• Conducts initial concurrent review process for all selected admissions to initiate the tracking process and identification of other key pathway or quality indicators as appropriate.
• In collaboration with the physician, nurse, and Medical Records coder, identifies and records principle and secondary diagnoses, principle procedures, and assigns a working Diagnosis Related Group (DRG).
• Identifies need to clarify clinical documentation in records, and initiates communication with the provider by utilizing the query process, in order to capture the documentation in the medical record that supports patient's severity of illness.
• Serves as an educator and resource to the medical staff and hospital staff regarding clinical documentation requirements.
• Promotes effective professional relationships with physicians, other department members and hospital staff; facilitates problem solving as appropriate.
• Identifies, evaluates, and acts to resolve any barriers to meeting documentation standards.
• Performs a thorough chart review to identify co-morbidities / complications and documents these appropriately on the clinical documentation worksheet.
• Utilizes monitoring tools to track the progress of the Clinical Documentation Assurance Program.
• Identifies quality variances that can be abstracted concurrently.
• Provides information and education as necessary to physicians and ancillary staff not responding to queries.

Major Responsibilities

• Conducts initial concurrent review process for all selected admissions to initiate the tracking process and identification of other key pathway or quality indicators as appropriate.
• In collaboration with the physician, nurse, and Medical Records coder, identifies and records principle and secondary diagnoses, principle procedures, and assigns a working Diagnosis Related Group (DRG).
• Identifies need to clarify clinical documentation in records, and initiates communication with the provider by utilizing the query process, in order to capture the documentation in the medical record that supports patient's severity of illness.
• Serves as an educator and resource to the medical staff and hospital staff regarding clinical documentation requirements.
• Promotes effective professional relationships with physicians, other department members and hospital staff; facilitates problem solving as appropriate.
• Identifies, evaluates, and acts to resolve any barriers to meeting documentation standards.
• Performs a thorough chart review to identify co-morbidities / complications and documents these appropriately on the clinical documentation worksheet.
• Utilizes monitoring tools to track the progress of the Clinical Documentation Assurance Program.
• Identifies quality variances that can be abstracted concurrently.
• Provides information and education as necessary to physicians and ancillary staff not responding to queries.

Licensure, Registration, And/or Certification Required

• Registered Nurse license issued by the state in which the team member practices.

Education Required

• Associate's Degree in Nursing.

Experience Required

• Typically requires 3 years of experience in an acute inpatient environment.

Knowledge, Skills & Abilities Required

• Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program.
• Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies helpful.
• Working knowledge of Medicare reimbursement and coding structures.
• Knowledge of care delivery documentation systems and related medical record documents.
• Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.
• Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
• Excellent written and verbal communication and critical thinking skills.

Physical Requirements And Working Conditions

• Manual dexterity required for operation computer and calculator.
• Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to a normal office environment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.