Clinical Document Spec Hourly
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JOB RELATIONSHIPS
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Reports to the Director of Research and Innovation in collaboration with the CNO/VP of Patient Care
Services and CMO/VP of Medical Affairs. Works with the entire patient care team.
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DEFINITION OF POSITION
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Responsible for concurrent and retrospective auditing of medical record documentation to evaluate
whether documentation adequately reflects the care provided, resources used, patient severity of
illness, and risk of mortality. Responsibilities include facilitation of appropriate physician and
Advanced Practice Provider (APP) documentation of care to accurately capture principal and
secondary diagnoses, comorbidities, complications, and procedures. Proactively solicits clarification
from physicians, APPs, and clinical staff in areas where further specificity, precision, or clinical
validity is needed in the documentation, and consults with the attending physician or APP when
conflicting or ambiguous information appears in the medical record. Conducts compliant clinical
documentation queries in accordance with AHIMA and ACDIS query practice brief guidelines.
Collaborates with third-party vendors, external coding auditors, and contracted CDI partners to
identify and act on documentation improvement opportunities. Participates in mortality case
reviews and collaborates with quality and medical staff to analyze documentation contributing to
unexpected mortality outcomes. Supports readmission reduction initiatives by reviewing
documentation related to potentially preventable readmissions and communicating findings to care
teams and leadership. Maintains documentation regarding results of audit activity and shares those
with staff and management as necessary. This position supports the concepts and philosophies of
nursing as well as sound business practices.
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QUALIFICATIONS
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Professional
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- Minimum of 3 - 5 years of clinical experience required with current nursing license.
- BSN and MSN preferred.
- Knowledge of current trends and issues in health care.
- Excellent communication and critical thinking skills. Computer experience required. Ability to work independently and meet deadlines and schedules is required. Knowledge of care delivery documentation systems and related medical record documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology.
- Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required.
- Keeps abreast of current regulations pertaining to job responsibilities.
- Assumes responsibility for continued professional growth and development.
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