Clinical Documentation Spec
Leonardtown , MD 20650
Posted 2 weeks ago
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* Job Summary * Reviews clinical documentation under the supervision of the Director of Performance Measurement and Corporate Compliance, reviews clinical documentation both concurrently and retrospectively for opportunities to improve physician documentation. Gathers data from clinical documentation improvement reviews to provide optimal APR-DRG assignments and severity levels of cases on a continuous, daily basis. Serves as a resource to physicians, case managers and other clinical staff to refine documentation and query processes. Supports the development of power plans, Best Practice guides and power notes in the electronic medical record (RUBY) to facilitate adherence to best practice guidelines and regulating compliance. * * Minimum Qualifications* Bachelors' degree in Nursing or the equivalent of Associates * Minimum eight (8) years experience as a Registered Nurse. * Minimum of 60% on Microsoft Word and Microsoft Excel skills testing. * * Preferred Qualifications * Experience in Case management, Utilization Review or Medial Coding. * Certification as Clinical Documentation Specialist. * Previous experience as a CDS. * * * Primary Duties and Responsibilities * Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations. * Reviews inpatient medical records both concurrently and retrospectively for identified payer populations as directed on admission and throughout hospitalization. Reviews Medical Records for Potentially Preventable Complications/Maryland Hospital Acquired Condition trends and intervenes as needed to ensure accuracy of reporting. Reviews charts for accurate portrayal of conditions that are present on patient admission and queries physicians as needed to ensure accuracy. * Consistently meet s established productivity targets for record review. * Communicates with attending physicians and other clinical staff either verbally or through written/on line methodology to validate observations and clarify additional and/or more specific documentation. * Works closely with Medical Coding staff to ensure documentation of discharge diagnoses and co-morbidities to provide a complete reflection of each patient's clinical status and care. Demonstrates and applies basic knowledge about standards of medical coding to the ongoing evaluation of medical record documentation. * In collaboration with physician leadership, suggests and implement specific tools to support documentation. * Develops and implements plans for both formal and informal education of physicians, nursing, medical record and other clinical staff. * Identifies and implements strategies for sustainable work process changes that result in complete, accurate clinical documentation. * Analyzes clinical status of patients, current treatment plans, history and physical information, and identifies potential gaps in documentation (e.g., APR-DRG requirements, CORE Measures, Stroke Care requirements). * Performs other duties as assigned.About MedStar HealthMedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.