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Purpose:

The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.

Responsibilities:

+ Participating at the organizational level in clinical documentation improvement initiatives

+ Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness

+ Preparing trended data for presentation one-on-one and small to medium groups of physicians

+ Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team

+ Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team

+ Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans

+ One of the following:

+ Minimum 3 years of clinical acute care nursing experience (medical/surgical, including critical care) and expanded knowledge of Diagnosis-Related Groups (DRGs), OR

+ Completion of Health Information Management program (RHIA) or Accredited Record Technician (RHIT) certification AND at least 3 years of experience with the Prospective Payment System (PPS) and DRG selection, OR

+ Specific knowledge and experience as a consultant in medical record coding and DRG assignment.

+ Strong ability to communicate professionally and diplomatically with physicians, staff, and healthcare providers.

+ Proficiency in computer technology and electronic health record systems.

Preferred Qualifications

+ Prior Clinical Documentation Improvement (CDI) experience.

+ Background in Quality Assurance, Utilization Review, or Quality Insights.

+ Advanced knowledge of DRGs, PPS, and coding guidelines.

+ Familiarity with quality metrics and compliance standards.

Key Skills

+ Excellent interpersonal and communication skills.

+ Analytical thinking and attention to detail.

+ Ability to work collaboratively across multidisciplinary teams.Licensure, Certifications, and Clearances:Employees practicing in Maryland: Respiratory Therapist license may be used in substitution of the aforementioned certifications and licensure.

+ Certified Coding Specialist (CCS) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Doctor of Podiatric Medicine OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN)

+ Act 34

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran