The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The CDS performs concurrent clinical documentation chart reviews to ensure the medical record appropriately describes the patient’s severity of illness and risk of mortality. The CDS develops compliant physician queries guided by the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Improvement Professionals.” In addition, the CDS may review medical records retrospectively, in accordance with the Hospital’s CDI policies and procedures, to identify whether or not the physician responded to a query placed concurrently. These functions are performed in accordance with all applicable laws and regulations and MedStar Georgetown University Hospital's philosophy, policies, procedures, and standards.
- EDUCATION/TRAINING: Bachelor of Science degree in a related field; BSN degree preferred.
- EXPERIENCE: Three years of experience in a tertiary hospital. Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems preferred.
- LICENSE/CERTIFICATION/REGISTRATION: RN required; Clinical Documentation Specialist credential (CDIP or CCDS) preferred. Upon hire, must become AHIMA or ACDIS-certified in CDI within 12 months of becoming eligible for the exam. Consideration will be provided for clinicians (i.e., graduates of medical schools outside the U.S. but not yet licensed to practice in the U.S.).
- KNOWLEDGE, SKILLS & ABILITIES: Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff. Demonstrates effective written and verbal communication skills. Demonstrates critical thinking skills and strong clinical knowledge. Is proficient in the use of computers to perform daily work, including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook and other applications necessary to perform the CDS role, such as an encoder or CDI workflow and reporting tool. Ability to collect and analyze data related to the CDI program.
Primary Duties and Responsibilities:
- Performs initial and follow-up CDI chart reviews in accordance with the Hospital’s CDI policies and procedures.
- Reviews the medical record and evaluates the documentation to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate MS-DRG or APR-DRG assignment/severity of illness and risk of mortality.
- Identifies opportunities for education based upon query topics or other identified need and provides ongoing education to physicians, clinicians and other stakeholders about the need for accurate, complete and consistent documentation in the medical record. Educational approach may include face-to-face interactions, formal presentations or in-services to the medical staff or clinical departments, newsletters, posters, etc.
- Develops written and verbal CDI physician queries in compliance with organizational and AHIMA standards, when there is missing, unclear or conflicting documentation in the record.
- Performs MHAC chart reviews in accordance with the Hospital CDI policies and procedures. Develops written MHAC physician queries to identify/clarify POA status, global exclusions and documentation to further clarify complications versus other stated conditions. Utilizes coding and CDI resources, including coding clinics, coding guidelines, AHIMA and ACDIS guidance, and clinical/pharmacology/disease process information, as needed, in an effort to apply the correct coding guidelines and clinical information to the review of the patient’s record.
- Demonstrates a cooperative, collaborative and team-oriented approach with CDI team, coders, case managers, nursing staff, medical staff, and other ancillary departments. Develops and implements an effective coder-CDS communication plan to ensure a coordinated, standardized and effective approach with clinicians.
- Inputs daily review data in a timely manner, including number of cases reviewed, number of queries placed, working MS-DRG or APR-DRG, secondary diagnoses, procedures, and Target/CDS MS-DRG or APR-DRG.
- Participates in the collection, analysis and trending of CDI data to identify opportunities for improvement and to develop education for medical and hospital staff.
- Demonstrates the appropriate utilization of paper and electronic CDI chart review resources (i.e., CDI worksheet) to foster transition of cases within the CDI team. Ensures the CDI worksheet includes precise clinical details to support physician queries and assist in the retrospective DRG reconciliation process.
- In accordance with the Hospital’s CDI policies and procedures and in partnership with coding professionals, the CDS participates in the retrospective review of principal and secondary diagnoses to ensure the accuracy of diagnostic and procedural data.
- Actively participates in identifying areas of opportunity to improve the success or mitigate barriers in the CDI program, and collaborates with the program Director to develop action plans to address issues.
- Maintains CDI credentials and seeks continuing education to stay current on CDI-related matters.
- Meets the organization's CDS performance standards including, but not limited to, productivity (initial reviews and follow-up reviews), query rate and documentation clarification rate.
- Performs other duties and responsibilities that are appropriate to the position and area.
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations.
A qualified individual with a disability will be considered for employment on the same basis as non- disabled applicants if he/she can perform the essential functions of the job sought, with or without a reasonable accommodation, and without imposing a direct threat to the health or safety of others or him/herself.