Clinical Documentation Spec

Clinical Documentation Spec JOB SUMMARY/PURPOSE Provides analysis, information and education to assist physicians and/or staff in using terminology that improves and supports documentation of patient care. Performs concurrent review and analysis of the clinical facts documented in the medical records. Concurrently queries the medical staff and other members of the healthcare team to obtain accurate and complete chart documentation that appropriately supports the severity of the patient's illness. Plans and provides education to the healthcare team regarding documentation requirements, clarity and completeness. DEPARTMENT DESCRIPTION The Clinical Documentation Improvement Department is the fundamental, strategic part of Samaritan Health Services’ efforts to improve patient outcomes, enhance clinical documentation guidelines, ensure compliance and upgrade financial performance. The CDI program is a comprehensive, multi-disciplinary, hospital wide initiative promoting accurate, clear, concise, complete, and compliant documentation efforts. CDI professionals analyze data, formulate concurrent & retrospective physician queries, track CDI performance metrics, and successfully collaborate with other healthcare professionals. CDI professionals engage in a beneficial collaborative partnership with the Healthcare team to secure accurate clinical documentation in the medical record using compliant methodologies, which will result in appropriate code assignment, correct reimbursement, decreased claims denials & reduced RAC reviews. EXPERIENCE/EDUCATION/QUALIFICATIONS One (1) of the following required: Current unencumbered Registered Nurse license in state of residence and five (5) years nursing experience in an inpatient acute care setting. BSN and experience in ICU-CCU preferred. Current Registered Health Information Technician Certification (RHIT) with CCS and six (6) years inpatient coding experience. Experience in the following required: Clinical Documentation. Inpatient Coding and Reimbursement. Quality assurance chart review, coding, auditing and/or case management. Acute care utilization review or discharge planning. Experience or training in Excel, Word and EMR required. Certified Clinical Documentation Specialist CDIS preferred. KNOWLEDGE/SKILLS/ABILITIES Knowledge of clinical documentation requirements, DRG assignment, clinical conditions/procedures, quality outcome standards and documentation requirements to meet those standards. Communication: Effective written and verbal communication skills to perform group presentations, tactfully discuss issues, and listen to and understand complex information/situations. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities. Computer Literacy: Proficiency in computer applications, including word processing, spreadsheets, databases, and information systems. Confidentiality: Knowledge of State and Federal (HIPAA) laws pertaining to confidentiality of protected health information. Ability to comply with laws and maintain confidentiality of patient information. Time Management: Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure. PHYSICAL DEMANDS Rarely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 40 - 60 Lbs LIFT (Floor to Waist: 0"-36") 60 or more Lbs SQUAT Static (hold >30 sec) KNEEL (on knees) SIT LIFT (Floor to Waist: 0"-36") 20 - 40 Lbs CARRY 2-handed, 20 - 40 pounds SQUAT Repetitive ROTATE TRUNK Sitting REACH - Upward PUSH (20-40 pounds force) PULL (20-40 pounds force) STAND WALK - LEVEL SURFACE LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs LIFT (Overhead: 54" and above) 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds CARRY 2-handed, 0 - 20 pounds BEND FORWARD at waist ROTATE TRUNK Standing REACH - Forward MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist PUSH (0-20 pounds force) PULL (0-20 pounds force) None specified PI4999ca93db8a-30511-38599647

Created: 2025-10-16