[Hiring] Clinical Doc Spec PRN @Wellstar Health System

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Role Description

The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes.
• Cooperates with physicians, other healthcare professionals and coding team to ensure accurate and complete clinical information in the medical record.
• Communicates and collaborates with CDI Leadership to support Clinical Documentation Improvement efforts.
• Reviews clinical documentation during patient admissions to identify opportunities for improvement.
• Facilitates modifications to clinical documentation to reflect patient severity of illness and risk of mortality.
• Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
• Performs concurrent hospital-wide medical record reviews to ensure coding compliance and improved patient outcomes.
• Submits documentation clarification queries to clinicians for accurate records.
• Ensures queries are compliant, grammatically correct, concise, and free of typographical errors.
• Provides appropriate follow-up on all queries.
• Escalates unanswered queries to the CDI Leadership team.
• Reconciles records daily in the Solventum/3M 360 Encompass CDI tool.
• Maintains required daily/weekly/monthly metrics and meets productivity standards.
• Participates in departmental meetings, conference calls, and presentations.
• Adheres to departmental Policies and Procedures.
• Submits ideas to improve workflow and increase team productivity/efficiency.
• Maintains knowledge of coding and billing rules and regulations.
• Educates patient care team members on documentation guidelines.
• Ensures accuracy and completeness of clinical information for reporting outcomes.
• Identifies areas for improvement in documentation and quality of care initiatives.

Qualifications
• Associates Nursing or Bachelors Health Science or Bachelors Nursing or Doctorate Medicine

Requirements
• All certifications are required upon hire unless otherwise stated.
• Cert Coding Spec or Cert Prof Coder or Reg Health Information Admin or Reg Health Information Tech or Reg Nurse (Single State) or RN - Multi-state Compact
• Cert Document Improvement Prac-Preferred or Cert Clin Document Specialist-Preferred
• Minimum 2 years of working in an acute care setting as a Clinical Documentation Specialist (CDS) Required.
• Minimum 5 years of healthcare experience Required.
• Epic and Solventum/3M 360 Encompass experience is required Required.
• Prior experience of working as a CDI/Coding auditor is preferred.
• Prior experience of working in inpatient case management or utilization review is preferred.

Skills
• Strong understanding of disease processes, clinical indications and treatments.
• Familiarity with encoder and current working knowledge of Coding Clinic Guidelines.
• Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity.
• Excellent communication skills, employing tact and effectiveness.
• Ability to interpret, adapt, and apply guidelines and procedures.
• Excellent problem-solving skills with practical and efficient solutions.
• Proficient computer skills in Microsoft Apps and CDI technology tools.

Benefits
• Support to do more meaningful work.
• Enjoy a more rewarding life.
• Connect with the most integrated health system in Georgia.

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