SHSMD Career Center

The Clinical Documentation Specialist provides clinical review of patient medical records to ensure documentation accurately reflects the level of clinical services, severity of illness and specificity of care. This position interacts with physicians, nursing staff, medical records coding staff, compliance specialists and other healthcare providers to ensure that clinical information in the medical record is accurate so that the appropriate utilizations, clinical severity, outcomes and quality are captured for the level of service rendered and ensures compliant reimbursement of patient care services.

RESPONSIBILITIES:

* Reviews and analyzes patient medical records to assess and procure accurate and complete documentation of patient diagnoses and procedures.

* Notifies attending physician and house staff officers or other disciplines promptly of documentation requiring clarification.

* Conducts follow-up reviews to ensure points of clarification have been addressed and recorded in the medical record and maintains an ongoing record of the results of each chart review, including responses to each intervention.

* Compiles and documents chart findings in dedicated CDI database on a daily basis.

* Translates diagnostic phrases utilized by healthcare providers into coded form and interacts with the healthcare provider to ensure that the terms have been translated correctly.

* Maintains awareness of the continual changes in federal and state regulations for prospective payment.

* Communicates with and educates members of the patient care team and clinical documentation team on an ongoing basis.

* Serves as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information.

* Facilitates ongoing education of staff in relation to chart documentation improvement techniques and practices.

* Assists as necessary with review of the medical record post discharge to determine coding status.

* Completes timely retrospective review for unanswered queries.

* Facilitates complete discharge summaries.

* Recommends strategies for improving record keeping processes.

* Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage.

* Reviews overall quality and completeness of coding by reconciling differences in the MS-DRG/APR-DRG assignment through comparison and analysis of the coding summary and CDI patient summary against the medical record documentation.

* Performs other duties as assigned.

QUALIFICATIONS / REQUIREMENTS:

Experience:

Minimum of three years of healthcare experience required with strong medical/surgical background. Experience with Coding/DRG, billing, auditing and reimbursement is preferred. Cerner Millennium Electronic Medical Record and 3M CDI Software experience is preferred. Thorough knowledge of ICD-10, MS-DRGs, documentation compliance standards and coding principles and guidelines.

Education:

Bachelor's degree in a healthcare field.

Licenses / Certifications:

One of the following active certification/licenses required: Clinical Documentation Improvement Practitioner, Certified Clinical Documentation Specialist, Certified Coding Specialist, or equitable coding credential. Preferred minimum requirement: RHIT/RHIA and current/active license as a registered nurse in the state of residence or current /active RN license with the ability to transfer license to state of residence within three months of start.

Other:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area's leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children's Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.