Clinical Documentation Specialist: DRG, Queries & Quality

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

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.