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Under limited direction and according to clinical documentation guidelines and established
policies/procedures, the Clinical Documentation Specialist is responsible for improving the overall quality
and completeness of clinical documentation.
Duties and Responsibilities:
_ Ensures the accuracy and completeness of clinical information used for measuring and reporting
physician and hospital pay for performance diagnosis specific quality outcomes.
_ Facilitates necessary documentation in the medical record through extensive interaction with
physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff to ensure
the most appropriate reimbursement is achieved for the level of service rendered to all patients.
_ Oversees clinical documentation patterns and trends to identify areas of improvement for the pay for
_ Educates all members of the patient care team regarding clinical documentation needs, changes to
clinical documentation guidelines, coding and reimbursement issues, and pay for performance
documentation requirements on an on-going basis.
_ Develops and conducts on-going documentation education for new staff including case managers,
coders, physicians, residents, nursing and allied health professionals.
_ Uses assertive interpersonal skills to discuss clinical documentation issues and work effectively with
all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and
some external customers including third party payors to resolve issues.
_ Articulates the program to physician and other health care professionals in order to educate and
teach clinical documentation requirements for both MS-DRG reimbursement and pay for
performance quality measures.
_ Facilitates the processes associated with the Documentation Improvement Initiative, encourage a
spirit of cooperation among clinicians, coders, physicians, etc., and direct others toward objectives
that contribute to the success of the program.
_ Must be able to travel to various locations as needed
Other Duties and Responsibilities:
_ May perform quality and documentation audits.
_ Meet with CDI Auditor/Educator to discuss potential educational opportunities or identify areas
of potential compliance issues.
Education, Experience & Licensure:
_ License to practice as a Registered Nurse
_ Certified Clinical Documentation Specialist (CCDS) certification required;
_ Minimum five years clinically well-rounded medical, critical, surgical acute care nursing experience
_ In-depth technical knowledge of ICD-10-CM/PCS and MS-DRG, medical terminology and
_ Advanced knowledge of coding/documentation and billing regulations related to commercial
insurance, Medicaid and Medicare.
_ Knowledge of medical coding including clinical documentation guidelines, policies and procedures,
and the requirements of third party payers most frequently seen with the hospital patient population.
_ Financial analysis billing or reimbursement experience preferred.
_ Experience with Electronic Medical Records
Skills & Requirements:
_ Analytical ability to gather and interpret data, to evaluate reports and track progress of initiatives and
to determine methods for ensuring coding compliance.
_ High degree of interpersonal skills to effectively communicate with physicians, management and
_ Must be able to work independently, and utilize problem solving techniques and critical thinking
_ Ability to analyze data for patterns and trends.
_ Excellent observation, communication and decision making abilities.
_ Ability to prioritize work, focus on completion of tasks and meet deadlines through strong
_ Demonstrated leadership skills through professionalism as a team player
_ Ability to use computer systems; computer skills and knowledge of various software packages
including database and spreadsheet programs.
Physical Requirements/Working Conditions:
Able to set and organize own work priorities, and adapt to change when needed. Must be able to
work concurrently on a variety of tasks/projects in an environment that may be stressful with
individuals having diverse personalities and work styles.
Ability to comply with Anthelio Healthcare Solutions' policies and procedures.
Able to spend majority of time utilizing a computer, monitor and keyboard.
Able to perform some lifting and/or pushing/pulling up to 20 pounds.
Able to work with interruptions and perform detailed tasks.
Proficient on working on different projects simultaneously and coordinate work to meet deadlines.
Skilled ability to concentrate and read for long periods of time.
Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting,
and reading. Must be able to sit for long periods of time.
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