Clinical Documentation Specialist II

The Clinical Documentation Specialist II is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers.

The Clinical Documentation Specialist II assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. This position conducts independent research to ensure compliance when developing provider queries, while interpreting and applying evolving standards from governing bodies AHIMA and ACDIS and maintaining up-to-date knowledge of coding changes and updates released each April and October.

Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with on-site meetings, zoom meetings, telephonic discussions, rounding and email. Additionally, the Clinical Documentation Specialist II will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.

Essential Functions :

• Performs extensive record reviews.
• Provider Communcation and Education.
• Documentation Improvement.
• Compliance and Query Development.
• Report clinical documentation improvement metrics.
• Perform other duties as assigned.

Experience and Education :

Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines.

(CCDS) Certified Clinical Documentation Specialists from ACDIS.

Minimum Skills / Specialized Training Required :

Preferred Experience :