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The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of services rendered to all inpatients.
- Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
- Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
- Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
- Participating at the organizational level in clinical documentation improvement initiatives
- Preparing trended data for presentation one-on-one and small to medium groups of physicians
- Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans
Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRGs; OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND 3 years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required. Prior CDI work experience preferred. Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred. Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required.
Licensure, Certifications, and Clearances:
- Certified Clinical Documentation Specialist
- Certified Coding Specialist or Certified Registered Nurse Practitioner or Doctor of Podiatric Medicine or Medical Doctor or Registered Health Information Administrator or Registered Health Information Technician or Registered Nurse
- Registered Nurse
UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities