Clinical Documentation Specialist

Renown Health

United States, Nevada, Reno

1155 Mill Street (Show on map)

Feb 16, 2025

Position Purpose

The purpose of this position is to evaluate and establish the appropriateness of the DRG (diagnosis related groups) or HHRG (home health related groups) assignment relative to the existing clinical documentation within the medical record provided by the health care provider. The clinician will identify potential DRG/HHRG assignment based on documentation and clinical indicators to improve the quality of documentation ensuring compliance established by State and Federal Regulations. Clinicians will also provide education to and collaborate extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.

DRG reviews are done by incumbent(s) housed in 200734

HHRG reviews are done by incumbent(s) housed in 200351

Nature and Scope

The Clinical Documentation Specialist reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The clinician is responsible for translating diagnostic phrases utilized by healthcare providers into coded form. The translation process requires interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then utilized for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large. The clinician is charged to assign the appropriate DRG/HHRG after concurrent review of the medical record.

The clinician must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for DRG/HHRG. The clinician must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. The clinician works as a part of a coding team to achieve and ensure that there is no coding disagreement with the DRG/HHRG.

The clinician must be a professional, team player, able to communication well with others. The clinician must have strong interpersonal skills, pleasing personality and maintain a positive attitude. The clinician will have regular significant contacts with other personnel throughout and outside the medical center. These contacts may be in person, by telephone, or through correspondence

This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in treatment modes and new procedures, and to clarify diagnoses when physician documentation is vague or missing.

DRG reviews are done by incumbent(s) housed in 200734

HHRG reviews are done by incumbent(s) housed in 200351

This position does notprovide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred

Name	Description
Education:	Must have working-level knowledge of the English language, including reading, writing and speaking English.
Experience:	Minimum 5 years acute care hospital experience / area of specialty practice in working as an RN is required. Knowledge of the ICD system and CDI experience is preferred.
License(s):	Ability to obtain and maintain a State of Nevada Registered Nurse license, or licensure from State in which they have residency.
Certification(s):	CCDS Certification Preferred
Computer / Typing:	Working knowledge of basic computer programs and Microsoft Office Suite. Keyboard typing required. Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.