Clinical Documentation Specialist

Advocate Health; North Wilkesboro (NC); On-site; USD 80,000 - 105,000; Full time

Job summary

Advocate Health is seeking a Registered Nurse with strong clinical documentation expertise to drive accurate DRG assignments and pre-bill reviews. You will educate physicians, collaborate with care teams, and uphold CDMP compliance to improve documentation quality.

The role requires five years of bedside nursing experience, a BSN, and ongoing opportunities for CCDS certification within two years. Inpatient experience across ED, ICU, or Med‑Surg is valued.

Qualifications

• Five years direct clinical nursing experience required.
• BSN degree from an accredited School of Nursing.
• Current license to practice as a Registered Nurse (RN).
• Professional certification in Clinical Documentation (CCDS) highly recommended within two years of hire.

Responsibilities

• Facilitates appropriate clinical documentation to support severity of illness and complexity of care.
• Reviews and resolves pre-bill clinical issues to ensure accurate DRG assignment.
• Collaborates with case managers, nursing staff, quality and analytics to resolve physician documentation queries prior to discharge.
• Provides one-on-one education to physicians and providers on documentation needs and ICD-10-CM/PCS guidelines.
• Ensures compliance with CDMP procedures and participates in department quality assurance activities.
• Utilizes software systems to collect data and ensure data integrity and accurate documentation.
• Supports age/developmentally appropriate patient care per Age-Specific Care Guidelines.

Job description

Major Responsibilities:

• Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. Follows CDMP processes for conducting medical record reviews, assigning a working MS-DRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation appears in the medical record prior to coding and billing. Consistently meets established productivity targets for record review.
• Reviews and resolves any clinical issues arising in the pre-bill stage of medical coding to insure the most accurate DRG has been assigned for billing purposes. Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation. Prompt and professional interactions are used to effectively to resolve any deficiency.
• Collaborates with case managers, nursing staff, quality and analytics and other ancillary staff as needed regarding interactions with physicians on documentation to resolve physician queries prior to patient discharge. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages communication by promoting open dialogue.
• Provides one-on-one education to physicians, mid-level providers and other key healthcare providers regarding the need for accurate, specific and complete clinical documentation in the patient's medical record. Support ICD-10-CM/PCS training for providers by reinforcing coding conventions and guidelines.
• Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation. Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation. Participates in departmental quality assurance activities.
• Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MS-DRG assignment, documentation requirements, ICD-10-CM/PCS code assignment and coding guidelines.
• Participates in clinical documentation compliance activities including hospital acquired conditions by assuring accurate documentation resulting in the most appropriate MS-DRG assignment. Conducts pre-bill medical record reviews, assuring compliance with coding and documentation guidelines. Identifies missed opportunities related to clinical documentation and coding guidelines. Seeks additional clarification of documentation from the physician as needed in the post-discharge period in order to ensure the medical record is complete and accurate. Follows CDMP procedures for moving medical records through pre-bill process in a timely manner.
• Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.
• Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served. Knowledge of physical, motor/sensory, mental, psychosocial, safety and developmental factors in the Age-Specific Care Guidelines is reflected in reviews of patient medical records and interactions with the multidisciplinary team.

Licensure, Registration, and/or Certification Required:

• Current license to practice as a Registered Nurse (RN) in the State of applicable state. Professional certification in Clinical Documentation (CCDS) highly recommended within two years of hire.

Education Required:

• Graduation from an accredited School of Nursing with BSN.

Experience Required:

• Five years direct clinical nursing experience required.

Experience Preferred:

• Five years direct inpatient bedside experience. Especially with ED, Acute Care, Med Surg, ICU, etc.

Knowledge, Skills & Abilities Required:

• Strong oral, written, listening, and interpersonal communication skills
• Experience in developing and presenting education programs
• Competent computer skills including knowledge of Excel, Microsoft Word, PowerPoint, and Microsoft Outlook Analytical skills
• Self-motivated, self-directed and able to work independently with minimal supervision
• Able to work in a collaborative atmosphere
• Ability to accept and incorporate critical comment
• Well organized and detail oriented Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions

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.