Reporting to the Manager, Healthcare Consulting (Interim staffing), the Clinical Documentation Specialist will be responsible for providing CDS staffing services for clients. He/she will be responsible for improving documentation by identifying documentation improvement opportunities, based on medical record reviews. Under the guidance of the Manager, the Clinical Documentation Specialist is accountable for meeting a productivity and quality standard. The CDS is responsible for customer service to both the internal and external customers. Working within a goal driven environment is essential. Nuance provides a rigorous orientation and training program as well as a progression ladder/plan that allows for the consultants’ professional growth.
Responsibilities:
- Reviews 8-10 new cases per day, conducting comprehensive medical record review for documentation completeness and accuracy, in addition to 12-15 follow-ups per day.
- Demonstrates proficiency in the use of all Nuance CDI software applications.
- Correctly identifies initial and possible DRG.
- Identify documentation improvement opportunities to improve severity of illness and DRG.
- Identifies documentation improvement opportunities by consistent use of software resources (decision trees, coding guidelines, references).
- Correctly sequences DRG to reflect the highest level of severity when two or more diagnoses are present on admission and equally meet the definition of principal diagnosis.
- Completes all required weekly, monthly, and quarterly CDI competencies, and education modules/offerings.
- Generates compliant and clinically valid clarifications using Nuance best practices, to ensure documented conditions in the medical record are clinically valid, present on admission, consistent, and not conflicting.
- Manages core measures and patient safety indicators when triggered during case review.
- Utilizes process flow map for concurrent and post discharge CDI processes.
- Participates in project work, as assigned by manager, which may include precepting, quality reviews, or data analytics.
- Represent Nuance in a professional manner always, upholding the core values of: integrity, innovation, time, results and Nuance corporate values.
- Perform tasks related to securing and keeping the products, tools, and processes that you are responsible for securing.
Qualifications
Number of Years of Work Experience: 3-5 year of bedside nursing experience.
Required Skills: Critical care, emergency or strong medical surgical experience; able to travel 25% annually; customer facing skills, critical-thinking skills, interpersonal skills, agility, problem-solving, and ability to collaborate with a team and client.
Preferred Skills: Current bedside nursing practice, current professional nursing certification, CDS experience, Excel skills, leadership skills, presentation skills, experience developing others, quality assurance experience.
Education: BSN required; MSN preferred