Clinical Documentation Improvement Specialist- Medical Center of Arlington
Medical Center of Arlington
North-Dallas/Ft. Worth, Texas
The Clinical Documentation Improvement Specialist (CDS) performs concurrent review of the medical record, issues concurrent physician inquiries, and interacts iwth the medical staff and other caregivers.
Clinical Documentation Improvement Specialist- Medical Center of Arlington(Job Number: CDS-002)
Texas - North-Dallas/Ft. Worth-Medical Center of Arlington- Arlington (Dallas/Ft.
Schedule: Full-time
Description
The Clinical Documentation Improvement Specialist (CDS) performs concurrent review of the medical record, issues concurrent physician inquiries, and interacts iwth the medical staff and other caregivers in an effort to assure complete and accurate documentation of the patients clinical picture and the treatment provided. The CDS acts as a liaison between Coding professionals and the medical staff.
The CDS duties include but are not limited to:
Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that the documentation of the level of service rendered to the patient and the patients clinical complexity is complete and accurate.
Reviews medical records and identifies potential gaps in clinical documentation for specified patients types and payor populations as directed on admission and througout hospitalization.
Queries physicians and other caregivers as necessary via approved written communicatin mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality
Completes concurrent review on 85% of assigned population
Achieves and maintains 95% accuracy rate
Works closely with coding staff to assure documentation of discharge diagnoses and any co-existing comorbidities or complications to completely reflect the patients clinical status and care
Demonstrates basic knowledge of coding standards and application to ongoing evaluation of medical record documentation
Develops and implements plans for both formal and informal educaiton of physician, nursing, and other clinical staff
Identifies strategies through data gathering and analysis of trends to establish recommendations for sustained work process changes that facilitate complete, accurate clinical documentation
Consistently meets established productivity targets for record review
Qualifications
Current active RN licensure in Texas required
Undergraduate degree in Nursing required
Minimum 5 years recent health informaiton management, case management/utilization/quality review and/or related clinical experience in an acute care faciltiy required
Superior clinical assessment skills and strong knowledge of cared devlivery documentation systems and related medical record documents required.
Must be able to develop collaborative relationships to facilitate the accomplishment of work goals, and possess excellent interpersonal skills in building, negotiating and maintaining crucial relationships.
Ability to proactively prioritize initiatives, effectively manage resources, and multi-task required
Effective communication skills in order to communicate clearly, proactively, and concisely with all levels of the healthcare team
Adaptability - maintaining effectiveness when experiencing majore changes in work tasks or the work environment; able to adapt to change with a positive outlook, adjust effectively to work within new work structures, processes, requirements, or cultures.
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