Job Description

POSITION PURPOSE

The Clinical Documentation Specialist (CDS) is responsible for concurrently reviewing the medical records of hospitalized patients to facilitate the accurate and complete representation of severity of patient illness, expected risk of mortality, and complexity of care of the patient through provider documentation. This involves extensive record review, interaction with physicians, mid-levels, nursing, ancillary staff, and coders. The CDS supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

• Reviews and analyzes health records to identify relevant diagnoses.
• Collaborates with physicians, nurses, other care givers and medical records coding staff to improve quality and completeness of documentation of care provided and coded.
• Works with Medical Records staff to query physicians to clarify ambiguous, conflicting or incomplete documentation.
• Provides direction for concurrent clarification to clinical documentation to ensure appropriate coding for reimbursement of clinical severity and services provided to patients with a DRG-based payer.
• Facilitates clarification to clinical documentation to ensure that the medical record represents an accurate clinical picture of the patient and intent of the provider.
• Demonstrates knowledge of and supports mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.
• Promotes individual professional growth and development by meeting requirements for mandatory continuing education, skills competency, supports department-based goals that contribute to the success of the organization; serves as preceptor, mentor and resource to physicians and less experienced staff.
• Demonstrates adaptability, problem solving and professional behavior at all times.Creates batches daily in Accounts Payable module by entering special check vouchers and/or invoices into system and matching to appropriate receiving document; post batch after review completed.
• Reviews entries to ensure accuracy; reviewing general ledger expense, payment date, discount if applicable, vendor, etc.
• Resolves or reconciles invoice discrepancies with Materials Management or vendor as appropriate.
• Processes contract payments ensuring that all payments are processed on a timely basis.
• Creates schedule payments listing each week, reviews list for appropriate payments, discounts, etc. Prints checks and prepares check packets.
• Reviews and/or compiles monthly Accounts Payable accrual.
• Works with department directors to research questions regarding purchases and expenses on monthly reports.
• Maintains vendor listing; forward set-up of vendor, address changes and other necessary corrections to Materials Management staff for entry in the computer system.
• Issues tax exemption certificates as appropriate.
• Complies reports, credit applications, correspondence, etc. as needed
• Assists with processing of 1099 tax forms at year end.
• Abides by the HMH Legal Compliance Code of Conduct.
• Maintains patient confidentiality and appropriate handling of PHI.
• Maintains a safe work environment and reports safety concerns appropriately.
• Performs all other related duties as assigned.

LATITUDE, CONTACTS/INTERACTIONS

All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.

Requirements

Education: Associates degree in health information services or related discipline required.

Experience: Five years of acute hospital coding experience & prior CDI preferred.

Licensure/Certification: Credentialed as a Registered Health Information Administrator (RHIA) or Technician (RHIT)

Required Skills: Must have strong analytical, data management, organizational and time management skills. Must demonstrate knowledge and skills necessary to provide CDI/CDS education and/or training to physicians

PHYSICAL DEMANDS AND WORKING CONDITIONS

Frequent: sitting, standing, walking, & reaching.

Occasional: lifting, carrying, bending, & squatting,

Visual and hearing acuity required. Work is inside, with good ventilation and comfortable temperature.

Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.

Benefits

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources

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