Remote Clinical Documentation Specialist - CDS Expert

Trinity Health; United States; Remote; USD 90,000 - 110,000; Full time

Job summary

Saint Alphonsus Health System seeks a Clinical Documentation Specialist to review medical records and optimize physician documentation for accurate severity of illness and mortality risk.

This remote, full-time role collaborates with physicians, HIM and nursing staff; you will input data into 3M 360 Encompass and Cerner PowerChart and provide education to staff to support compliant documentation improvements.

Qualifications

• Registered Nurse, BSN preferred; or Certified Physician Assistant (PA-C).
• 3 to 5 years of hospital clinical documentation experience required; critical care or medical-surgical background preferred.
• Ability to pass written clinical competency exam.

Responsibilities

• Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.
• Ability to quickly learn and develop the skills necessary to perform the CDS role, including ability to accurately input relevant data into 3M 360 Encompass and Cerner PowerChart (special purpose software).
• Revenue Management
• Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient.
• Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications.
• Formulates credible and compliant clarifications to improve clinical documentation of principle diagnosis, co-morbidities, evidence of indicators representing conditions present on admission (POA), and quality core measures.
• Facilitates modifications to clinical documentation of the medical record through extensive interaction with physicians, nurses, and ancillary staff.
• Develops and implement plans of education of physicians, nursing, and ancillary staff on documentation improvement.
• Reviews inpatient medical records for all payer populations on admissions and throughout hospitalization.
• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
• Able to communicate effectively and appropriately with individuals at all levels of the organization.
• Actively participate in cross functional Task Force meetings.
• Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Able to effectively communicate with HIM staff and resolve discrepancies.
• Responsible for completing all annual regulatory compliance education, as well as CDS-specific assigned education.
• Understand and support compliant documentation strategies.
• Knowledge of pathophysiology and disease process.
• Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred.
• Excellent organizational, analytical, and writing skills.
• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills.
• Excellent time management skills and the ability to manage multiple priorities effectively.

Skills

Clinical documentation

Education

Registered Nurse (RN) with BSN preferred

Certified Physician Assistant (PA-C)

Tools

3M 360 Encompass

Cerner PowerChart

Job description

Saint Alphonsus Health System seeks a Clinical Documentation Specialist to review medical records and optimize physician documentation for accurate severity of illness and mortality risk.

This remote, full-time role collaborates with physicians, HIM and nursing staff; you will input data into 3M 360 Encompass and Cerner PowerChart and provide education to staff to support compliant documentation improvements.