Job Code:	1337
Job Title:	Clinical Documentation Specialist
Creation Date:	09/21/96
Revision Date:	09/19/09
FLSA Status:	Exempt

JOB SUMMARY:

To facilitate the improvement of the overall quality, completeness and accuracy of medical record documentation. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the patient care team and coding staff. To ensure clinical documentation reflects the level of service, severity of illness and is complete and accurate.

ESSENTIAL JOB FUNCTIONS:

• Concurrently reviews inpatient admissions to identify opportunities to improve the quality of documentation.
• Complies with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.

• Initiates physician interaction to clarify ambiguous or conflicting documentation, and assure any clarification is noted in the patient record according to policy.

• Maintains a positive and open communication with physicians, members of the patient care team, and coding staff.

• Assumes responsibility for professional development by participating in workshops, conferences and/ or in-services.
• Relates the importance of complete documentation on coding quality, DRG assignment, physician profiling, case mix index and expected mortality rates.
• Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Understands the general flow of health information from medical record documentation and discharge, coding, billing and finally data reporting.
• Adheres to internal controls and reporting structure.

MARGINAL OR PERIODIC JOB FUNCTIONS:

• Performs related duties as required.

REQUIRED EDUCATION / EXPERIENCE:

Bachelor's Degree in Allied Health, Nursing or related field with two years experience in acute care inpatient hospital setting OR Associate's Degree in Allied Health, Nursing or related field with 4 years experience in acute care inpatient hospital setting.

EQUIPMENT:

Standard office equipment.

WORKING ENVIRONMENT/LOCATION OF POSITION:

Standard office and patient care environments.   90% of time spent on patient care units interacting with clinical staff.

OTHER:

Specific job requirements or physical location of some positions allocated to this classification, may render this position security sensitive, and thereby subject to the provisions of Section 51.215, Texas Education Code.

ANY QUALIFICATIONS TO BE CONSIDERED AS EQUIVALENTS IN LIEU OF STATED MINIMUMS REQUIRE THE PRIOR APPROVAL OF THE VICE PRESIDENT FOR HUMAN RESOURCES AND EMPLOYEE SERVICES.