Overview

• Under the direction of the Site Manager of the Clinical Documentation Integrity (CDI) program, the Clinical Documentation Specialist (CDS) strives to achieve accurate and complete documentation in the inpatient medical record to support precise ICD-10-CM and ICD-10-PCS coding and reporting of high-quality healthcare data. The CDS is guided by the Association of Clinical Documentation Integrity Specialists (ACDIS) "Code of Ethics" and the American Health Information Management Association's (AHIMA) "Ethical Standards for Clinical Documentation Integrity Professionals" and the Official Guidelines for Coding and Reporting as approved by the Cooperating Parties.

• Key Responsibility 1: Performs concurrent initial chart reviews within 24-48 hours after admission with follow-up reviews occurring every 1-3 days, and retrospective chart reviews, when applicable, to accurately assign/capture the APR-DRG, severity of illness (SOI) and risk of mortality (ROM) in order to reflect quality indicators, resource consumption and outcome measures to ensure accurate and complete documentation for final coding and billing. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in provider documentation.

  * Key Responsibility 2: Communicates with providers either verbally or through written methodology to validate observations. Develops provider queries, in compliance with organizational and AHIMA standards when documentation in the medical record pertaining to a significant reportable condition or procedure or other reportable data element is conflicting, incomplete or ambiguous. Utilizes a comprehensive and strong clinical skill set, background and experience in acute care, exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately in order to decipher complex clinical cases. Adds detail and/or acuity to ambiguous or implied diagnoses. Will verify if a diagnosis was Present on Admission (POA) and establish the clinical significance and suspected etiology of a finding. Works concurrently to ensure documentation of discharge diagnosis (es) and any co-existing comorbidities are a complete reflection of the patient's clinical status and care. Evaluates medical record documentation using knowledge about HIM Standards of Coding. Monitors work progress and data to strengthen areas of focus. Consistently meets established productivity metrics for record review.

  * Key Responsibility 3: Identifies opportunities for education based upon query topics or other identified need for accurate, complete and consistent documentation in the medical record. Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support medical record documentation. Participates in both formal and informal education sessions including presentations, in-services, face-to-face interactions, newsletters, posters, etc. to the medical staff or clinical departments. Attends service line clinical program meetings and CDI meetings as requested. Identifies strategies for sustained work processes that facilitate complete, accurate clinical documentation. Manages initiatives to support accurate case-mix and quality documentation.
  
  * Key Responsibility 4: Acts as a clinical liaison between HIM/coding staff and providers. Partners with coding professionals to perform reconciliation, per policy, to ensure accuracy of diagnostic and procedural data in order to validate the CDS Final APR-DRG/ SOI/ROM against the Final Coded APR- DRG/SOI/ROM.

  * Key Responsibility 5: Seeks continuing education opportunities in order to stay current on CDI matters and/ or to maintain credentials.