Steward Health Care System
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FT - Clinical Dcmntn Spec
at Steward Health Care System
Clinical Documentation Specialist serves as a liaison for Health Information Management, working closely with the medical staff, nursing staff and Resource Management staff in support of excellence in patient information documented in the medical record. The primary purpose of this role is to ensure that all diagnosis, care, and treatment are documented in support of patient care and accurate DRG/APC assignment. Improves coding specificity by education physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of care provided. This work includes medical necessity, capturing complications / comorbidities during the patient’s stay. The CDS is accountable for concurrent review of medical records to track documentation supporting the severity of the illness and the resources utilized. A concentrated effort is put forth on patients concurrently with diagnosis which have the potential to be in the population of educational resources necessary to assure compliance with federal, state, and private rules and regulations on data collection, coding, and reimbursement. To provide a mechanism and guidelines to assure documentation by the physician. To meet the Medicare Conditions of Participation requirements that “medical records contain complete information / documentation regarding evaluations, interventions, care provided, services, care plans, discharge plans, and the patient’s response to those activities.”
Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Will play a significant role in obtaining accurate and compliant reimbursement for acute care services and in reporting quality of care outcomes. Must possess a current, valid RN or LPN license or an RHIA, RHIT, or CCS credential. Minimum of 3 years clinical or inpatient coding experience in an acute care setting required.
Years of Related Experience:
- Minimum: 2-4
- Preferred: 5-8
- Current/Active Florida Registered Nurse License (RN), Licensed Practical Nurse License (LPN), OR Registered Health Information Technician (RHIT)
- Education 3: Technical School/2 Years College/Associates Degree