Job Description
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Role Description
- The Clinical Documentation Specialist II improves the accuracy and quality of inpatient medical record documentation to ensure correct DRG assignment, coding integrity, and optimized reimbursement. The role includes:
- Timely chart reviews
- Identification of documentation gaps
- Issuance of clinically sound queries with high response and agreement rates
- Collaboration with providers and interdisciplinary teams
- Maintenance of accurate data in 3M 360 and Epic
- Support for financial and quality review projects
- Mentoring new staff
- Assistance to Rehab services with compliance and tier optimization
Strong clinical reasoning, ICD‑10/DRG knowledge, and communication skills are essential.
- Qualifications
- License/Registration/Certification: R.N. or Medical Graduate
- Education: R.N. Certified preferred; Medical School Graduate; Bachelor's Degree
- Experience: Critical Care/Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired
- Requirements
- Applies ICD-10 coding guidelines appropriately and has an 85% Working DRG accuracy
- Good working knowledge of all DRG and their structure, as well as CCs and MCCs
- Reviews all patient records in assigned unit(s) between 24-48 hours of inpatient admission
- Manages approximately 16-20 charts daily
- Recognizes opportunities for documentation improvement
- Formulates clinically credible queries to physicians
- Maintains excellent rapport with healthcare providers
- Maintains query rate of 25-35% of all patient records reviewed
- Follows up on all pending queries daily
- Good command of 3M 360 Encompass software
- Responsible for retrospective reviews for quality and revenue projects
- Documents query narrative and notes expected and actual responses
- Responsible for mentoring and training new employees
- Reviews mismatch report periodically
- Supports manager in reconciliation of monthly query reports
- Works individual monthly financial report
- Reports accounts with unanswered queries
- Provides support to Rehab team by reviewing potential rehab admissions
- Benefits
- Health benefits
- Life insurance
- Long-term disability coverage
- Healthcare spending accounts
- Retirement plan
- Paid time off
- Pet Insurance
- Tuition reimbursement
- Employee assistance program
- Wellness program
- On-site housing for select positions
- And more!
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