CLINICAL DOCUMENT SPECIALIST

General Purpose of Job:

Utilize clinical expertise to evaluate concurrent documentation and appropriate levels of service delivered to patients at Sparrow Hospital. Through extensive interaction with providers and multidisciplinary team members, the CDS will be responsible for facilitating modifications to overall quality and completeness of the medical record and information that is utilized in the profiling and outcomes reporting of both Sparrow Hospital and its providers. This role will interface with management and key physician leaders at the hospital as it prepares strategically for a competitive and solid future in today's health care market.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Perform complete and timely medical record review
• Enter appropriate and accurate data into tracking software in accordance with established departmental procedure
• Demonstrate knowledge and understanding of inpatient ICD-10 CM and ICD-10 PCS coding guidelines, and apply those guidelines in the selection of appropriate DRG and code assignments
• Analyze clinical information to identify areas within the chart that represent potential gaps in provider documentation
• Formulate clinically credible and compliant documentation clarifications
• Follow departmental procedures regarding chart review, query follow-up, and query escalation
• Consistently demonstrate excellent written and verbal communication skills in all interactions with providers and other caregivers
• Engage in short and/or long-term CDI committee assignments as needed
• Participate in, and contribute to the development of ongoing education of medical staff, CDS team members, and other caregivers
• Participate in team discussions, and share nursing specialty knowledge through formal and informal presentations
• Exhibit proficiency in utilizing reference materials, including coding clinics, coding rules and guidelines, coding manual, AHIMA and ACDIS references, and the CMS website
• Maintain professional growth and development through seminars, webinars, and professional affiliations to keep abreast of latest trends in CDI.