"Alerted.org

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Clinical Documentation Specialist is responsible for the review of inpatient medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals and nursing staff. Active participation in team meetings and education of the clinical staff in clinical documentation improvement are key functions of the role.

The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

JOB DUTIES AND RESPONSIBILITIES

ESSENTIAL FUNCTIONS:

Following orientation period, meets established productivity targets for new and follow-up inpatient record reviews per day. If unable to perform reviews, seeks assistance from peers or supervisor.

Formulates credible clinical documentation clarifications in 360’ format to improve clinical documentation of principal diagnosis, co-morbid conditions, present on admission status, and quality initiatives that support patient’s severity of illness, risk of mortality and patient safety indicators.

Maintains an accuracy rate of 94% or greater in identifying correct concurrent initial and possible DRG when 2 or more diagnoses meet definition of PDX; reconciles correctly after coding to reflect highest severity and relative weight; ensures documented conditions, clarifications, and coded diagnoses are clinically valid and compliant; conducts follow up reviews utilizing department approved case prioritization methods; and utilizes process flow map in both concurrent and post discharge processes.

Utilizes effective and appropriate verbal and written communication with physicians and other providers of record to validate observations and clarify additional and/or more specific documentation to accurately reflect the patient’s condition. Manages electronic communication efficiently and effectively.

Demonstrates knowledge of International Classification of Diseases coding regulations, applies to ongoing evaluation of medical record documentation, and works closely with Coding staff to assure documented diagnosis (es) and co-morbidities gives a complete and compliant reflection of the patient's clinical status and care.

Accurately inputs and analyzes data with the Clinical Documentation and performs re-reviews on a timely basis to identify changes in a patient’s condition through follow up or by writing new clarifications.

Demonstrates competency in computer and network applications as necessary to perform role.

Completes educational strategies to keep skills/knowledge current in documentation process and assists and supports with ongoing education for both formal and informal education of physician, nursing, and other clinical staff.

Works collaboratively with healthcare team to facilitate documentation. Maintains good rapport and cooperative relationships. Approaches conflicts in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.

Maintains confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.

Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.

Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external).

Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.

Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

Complies with Network and departmental policies regarding attendance and dress code.

Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.

OTHER FUNCTIONS:

Other related duties as assigned.

PHYSICIAL AND SENSORY REQUIREMENTS: Sitting for up to 7 hours per day, 3-4 hours at a time; standing for up to 7 hours per day, 4 hours at a time; walking for up to 2 hours a day, 1 hour at a time. Requires crouching, kneeling, and lifting of objects weighing up to 40 pounds. Requires hand and finger dexterity to use computer equipment. Proficiency in keyboarding and use of computer mouse. Ability to perform focused record reviews in a setting that may include noise or other distractions. Seeing as it relates to general, near, color and peripheral vision. Hearing as it relates to normal and telephone conversations. Ability to walk and stand 80% of work time.

POTENTIAL ON-THE-JOB RISKS: None Identified.

Fit Tested Statement:

Employees who work in patient care areas where they may have potential exposure to patients with suspected or proven tuberculosis (TB) must have the ability to wear a particulate respirator and be fit-tested in compliance with the current recommendations from the CDC (enforced by OSHA) or must provide physician documentation as to the inability to wear a particulate respirator.

SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE: None Identified

MOST COMPLEX DUTY: Ability to formulate clinically credible documentation clarifications, apply standards related to coding of patient medical record, and effectively communicate the necessity for meeting these standards to medical staff members.

SUPERVISION (RECEIVED BY AND/OR GIVEN TO): Supervised by the Network Manager, Clinical Documentation

COMMUNICATIONS: Communicates with Medical staff, Coding professionals, and other departments.

ADDITIONAL REQUIREMENTS:

Background knowledge of HIM field helpful, with focus on MS-DRG reimbursement, AHA coding guidelines and compliance preferred. Knowledge of regulatory environments, including familiarity of Medicare Part A and Part B.

MINIMUM QUALIFICATIONS

EDUCATION: Registered Nurse required, BSN preferred. Will consider NP, PA, or physician. Current license required. Prior clinical documentation specialist experience and credential preferred.

TRAINING AND EXPERIENCE: Minimum five (5) years RN/licensed provider experience in adult inpatient medical-surgical or critical care with thorough understanding of disease processes. Background knowledge of HIM field helpful, with focus on MS-DRG reimbursement, AHA coding guidelines, and compliance.

KNOWLEDGE/SKILLS:

Self-directed and takes initiative to improve departmental workflow and to further hospital goals and objectives. Maintains high-level customer service skills required for interpersonal and interdepartmental relationships. Critical thinking, problem solving and deductive reasoning skills. Must demonstrate responsibility and follow-through with assigned projects, service and support. Possesses well-developed verbal and written communication skills. Works closely with other departmental managers, technical teams and staff.

WORK SCHEDULE: Monday through Friday daytime hours with weekend rotation and/or as job demands.

Revised 2/2010; 8/2010; 8/2011, 9/2011, 5/2014, 2/2019

Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer. (http://www.slhn.org/EOE)