Clinical Documentation Specialist

Rochester Regional Health; Remote; GBP 58,000 - 72,000; Full time

Job summary

A healthcare organization in the United Kingdom is seeking a Clinical Documentation Specialist to enhance documentation accuracy in medical records. The role involves reviewing records for medical accuracy, collaborating with healthcare professionals, and ensuring compliance with documentation standards. Ideal candidates will have a Registered Nursing degree, relevant experience in acute care settings, and proficiency in clinical documentation improvement. This full-time, remote position offers competitive compensation and development opportunities.

Qualifications

• 3-5 years in adult acute care, especially in med/surg, critical care, or emergency room.
• RN degree required; BSN preferred.
• Previous CDS experience preferred.

Responsibilities

• Review medical records for completeness and accuracy.
• Recognize opportunities for documentation improvement.
• Provide education on the CDS process.

Skills

Adult acute care experience

Clinical documentation improvement

Communication with physicians

Data input accuracy

Education

Registered Nursing Degree

BSN preferred

Job description

Job Title: Clinical Documentation Specialist
Department: Clinical Documentation Improvement
Location: Riedman Campus (Remote)
Hours Per Week: Full-Time, 40 hours/week
Schedule: Day Shift (8am-5pm)

SUMMARY

The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with physicians, health information management professionals, and nursing staff.

ATTRIBUTES

• 3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.
• Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.
• Previous CDS experience preferred

Skilled Nursing Facility Only

• 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility
• Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.
• OR a degree in Health Information Management

RESPONSIBILITIES

• Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety
• Effective and appropriate communication with physicians
• Provides education to members of the patient care team regarding the CDS process.
• Timely follow up on all cases and resolution of those with clinical documentation clarifications
• Actively participate in Team Meetings
• Manage multiple priorities
• Communicates with HIM staff and resolves discrepancies
• Accurate input of data into department software

Skilled Nursing Facility Only

• Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
• Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
• Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.

Required Licensure/Certification

• RN, PA, NP, MBBS or MD prepared candidates
• If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire
• CCDS certification not required for legacy Unity team members hired before 12/31/2016.

Skilled Nursing Facility Only

• Valid RN or LPN license, or another applicable professional license, or RHIT, or RHIA
• Must obtain CCDS or CDIP certification within 30 months of hire

EDUCATION

• AS: Nursing (Required)

PHYSICAL REQUIREMENTS

S - Sedentary Work - Exerting up to 10 pounds of force occasionally. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

LICENSES/CERTIFICATIONS

• RN - Registered Nurse - New York State Education Department (NYSED)
• BLS - Basic Life Support - American Heart Association (AHA)

PAY RANGE

$78,000.00 - $96,200.00