The Clinical Documentation Specialist (CDS) is responsible for performing concurrent reviews of inpatient medical records to ensure clinical documentation accurately reflects the patient's severity of illness, risk of mortality, intensity of services, and quality of care provided. This role plays a critical part in supporting accurate DRG assignment, regulatory compliance, quality metrics, and organizational reporting.
The CDS collaborates closely with physicians, coders, CDI leadership, and ancillary departments to identify documentation clarification opportunities and ensure medical records support appropriate reimbursement and quality outcomes.
Experience with Applications 360, 3M, and Iodine is highly desired.
Perform concurrent and follow-up medical record reviews for selected admissions to initiate and support the clinical documentation improvement process.
Verify that clinical conditions are documented clearly, consistently, and in diagnostic format to support accurate coding, DRG assignment, and length of stay.
Identify opportunities for documentation clarification related to diagnosis specificity, inconsistencies, quality of care, patient safety, and resource utilization.
Assign working principal and secondary diagnoses and procedures to determine a concurrent DRG based on the clinical picture.
Collaborate with physicians, medical staff, coders, and CDI leadership to reconcile DRG mismatches and support accurate final DRG assignment.
Query providers in a compliant, professional manner to obtain accurate and complete clinical documentation.
Meet departmental productivity standards for initial, secondary, retrospective reviews, DRG mismatch analysis, and query follow-ups.
Achieve required quality, compliance, workflow, and outcome benchmarks as measured through monthly audits.
Maintain a strong working knowledge of coding guidelines and CMS, NCHS, and AHA regulations and their impact on reimbursement and quality metrics.
Utilize multiple systems and tools effectively, including but not limited to 3M 360, EPIC, Outlook, Iodine, Microsoft Teams, Zoom, and SharePoint.
Maintain strict adherence to HIPAA regulations and patient confidentiality standards.
Work independently and productively in a remote environment while complying with company security and remote-work policies.
Participate in special projects and perform other duties as assigned within scope of role.
Strong clinical knowledge and analytical chart review skills
Excellent verbal and written communication abilities
Ability to educate and collaborate collegially with medical staff and interdisciplinary teams
Strong organizational skills with the ability to prioritize and multitask
High level of accuracy, attention to detail, and critical thinking
Proficiency with computers, internet-based tools, and word processing applications
Positive, professional, and constructive interpersonal approach
Required:
MD, BS, or higher degree in a healthcare-related field OR
Licensed coder (CCS) with strong clinical knowledge and background
Clinical licensure (RN, PA, NP, MD, or FMD) and/or CCS certification required
Preferred:
CCDS and/or CDIP certification