Remote Clinical Documentation Specialist (CDS)

Job Description

JOB DESCRIPTION:
The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical/coding expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record and to support increased coding accuracy.

ESSENTIAL FUNCTIONS:
• Promotes a partnership between CDS, medical record coding, and physicians to improve documentation and coding integrity.
• Provide guidance to the physicians, nursing, and ancillary staff on clinical documentation best practices. They must be self-motivated and be adaptive to change.
• Analyze medical record documentation and other references such as MAR, Labs, Orders, etc. to validate clinical validity of reportable diagnoses and procedures, identify viable working DRG, and identify documentation opportunities and initiate concise and compliant queries.
• Concurrent initial, continued stay and retrospective audits with accurate CDS workflow data entry and scopes consistent with client work standards.
• Query initiation, follow up, escalation, etc. aligned with client scope and work standards.
• Adhere to AHIMA/ACDIS query compliance guidance and all Official ICD10 Coding Guidance.
• Adherence to any client specific diagnosis clinical validity criteria.
• Understand medical terminologies, procedures, and applicable laws to collect and
evaluate medical documentation.
• Demonstrates actions consistent with company's “Expectations” as duties are performed on a daily basis.

COMPANY EXPECTATIONS/GOALS:
• Complete mandatory annual HIPAA and Compliance Training in a timely manner
• Maintain confidentiality in all matters to include patient care, physician, and employee matters
• Maintain accurate and reliable organizational records
• Maintain professional relationships with appropriate officials; communicate honestly and completely; behave in a fair and nondiscriminatory manner in all professional contacts
• Assure the accuracy of data, work, or information and contribute ideas and suggestions to improve approaches, methodologies, and productivity.
• Maintain professional relationship with clients focusing on high level of client satisfaction
• Adhere to a personal plan of professional development and growth through professional affiliations, activities, and continuing education
• Support overall strategic goals of the company

HOME OFFICE REQUIREMENTS:
• Must have a dedicated secure workspace to ensure adherence to HIPAA Privacy and Security
policies and procedures when viewing protected health information (PHI)
• High-speed internet connection
• Telephone and printer/fax/scanner
• Company will provide laptop and access to necessary resources to perform job duties

EDUCATION, TRAINING, EXPERIENCE:
• RN / BSN Degree required
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and
written communication.
• Professional, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive.
• Flexible with a working knowledge of all areas of adult medicine.
• Good critical thinking skills, able to assess, evaluate, and teach.
• Flexible with strong knowledge of all areas of adult medicine.
• AHIMA coding credential of CCS or CDIP or ACDIS credential of CCDS is preferred.
• Minimum of 5 years of acute inpatient hospital experience in a large tertiary hospital required. Experience with second level reviews, CDI quality review and consulting preferred.
• Experience with electronic health records (i.e., Cerner, Meditech, Epic, etc.) required.
• Experience working remotely required.
• Ability to work independently required.
• Excellent planning and organizational skills required.
• Teamwork and flexibility required.
• Proficient in Microsoft Office Word and Excel programs.

PHYSICAL DEMANDS:
• This is a full-time position, and general hours of work and days are Mondays through Fridays, 8:00
a.m. to 5 p.m.
• Overall physical workload is light. Ability to communicate both orally and in writing. Moving about in excess of 70% of the day in order to carry out duties in a fast-paced environment. Sometimes work is generally sedentary requiring long periods at workstation.
• Travel may be required occasionally.