The Clinical Documentation Specialist assesses and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, clinically validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. This is a remote position, requiring on site visits less than 2 times per month.
Essential Job Outcomes:
Completes initial concurrent review process and subsequent reviews for all selected admissions to initiate the clinical documentation review process and documents findings. Identifies opportunities with regard to utilization guidelines, quality of care and patient safety.
Identifies opportunities and records principle and secondary diagnoses, principle procedures and assigns a working DRG. Collaborates with the medical record coders and CDI Coordinators to determine a working and final DRG representing accurate severity of illness, treatment and intensity of care.
Queries the medical staff and other members of the healthcare team to obtain accurate and complete chart documentation that appropriately supports the severity of the patient’s illness.