SUMMARY:

Under general supervision of Manager of Clinical Documentation, The Clinical Documentation Specialist is responsible for concurrent auditing of medical record documentation to assist with evaluating and improving the quality of clinical documentation of services to accurately reflect severity of illness, expected risk of mortality, and complexity of care of the patient.
Communicates and collaborates with physicians, mid-level providers, nursing staff, and other patient caregivers to improve quality and completeness of documentation.
Communicates and collaborates with the coding staff to ensure patient documentation is coded to the highest specificity.
Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

Instill Trust and Value Differences
Patient and Community Focus and Collaborate

RESPONSIBILITIES:

• Demonstrates a thorough and current knowledge of clinical care and treatment of assigned patient population to critically assess appropriateness of documentation, care and treatment.
• Able to identify PDX, MCCs, CCs, diagnoses that will impact SOI and ROM and risk adjustments.
• Responsible for concurrent auditing of the medical record on admission and throughout the hospital stay to ensure the documentation is a complete reflection of the patient's severity of illness, expected risk of mortality and care.
• Analyzes the clinical status of the patient, current treatment plan and past medical history and identifies potential gaps in documentation.
• Identifies opportunities to clarify incomplete, ambiguous, and conflicting documentation.
• Develops concise, effective, and compliant written and verbal queries. Effectively communicates with physicians/mid-level providers to discuss the patient's care as it relates to severity of illness and expected risk of mortality.
• Provides just in time education to physicians/mid-level providers and other members of the healthcare team regarding documentation requirements.
• Identifies documentation opportunities that may require formal education.
• Participates in informal and formal education sessions.
• Develops proficiency with the 3M encoder. Accurately enters diagnoses and procedure codes to assist with assignment of MS-DRGPR-DRG.
• Applies basic knowledge of HIM standards of coding to on-going evaluation of medical record documentation. Accurately identifies the working and CDS DRG based on documentation reviewed.
• Maintains the CDI Database for accurate capture of pertinent patient information and data.
• Performs effective and timely DRG reconciliation to ensure the most accurate DRG, principal diagnosis and all appropriate secondary diagnoses/procedures have been captured.
• Communicates with the coding staff to resolve discrepancies. Accurately enters data to reflect the reconciliation process.
• Acts as a clinical liaison between The HIM Coding Staff and physicians/mid-level providers regarding clinical documentation issues.
• Consistently meets established productivity targets for record review – optimal performance is established at the following:

Year 1 - 2: 16 - 22 reviews per day comprised of a mixture of initial chart reviews and re-reviews.
Year 2+: 20 - 24 reviews per day comprised of a mixture of initial chart reviews and re-reviews.

• Maintains knowledge of current standards and requirements for clinical documentation as defined by the centers for Medicare and Medicaid Services, Joint Commission, State of Rhode Island and other regulatory or certifying agencies identified by Brown University Health Corporate Compliance.

MINIMUM QUALIFICATIONS:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

QUALIFICATIONS:

Registered nurse with current licensure to practice in the State of Rhode Island with 3 years of relevant clinical experience (BSN required, master 's degree preferred).

Physician Assistant or Nurse Practitioner with current licensure to practice in the State of Rhode Island with 3 years of relevant clinical experience, or successful completion of education required for a medical degree with 2 years of clinical documentation experience.

Pay Range:

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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