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Under the direction of the Clinical Documentation Improvement Supervisor, the Clinical Documentation Specialist uses clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation of patient records on a concurrent basis using a multidisciplinary team process. Works collaboratively with physicians to ensure clinical information in the medical record is present and accurate. This position collaborates with Coding to support the appropriate severity of illness and risk of mortality. The Clinical Documentation Specialist (CDS) will interact with physicians and ancillary staff providing education regarding documentation clarification. Works in collaboration with hospital departments to support efforts that justify medical necessity, admission, continuity of patient care and other clinical documentation requirements.
SCOPE AND COMPLEXITY:
Information normally available when solving problems and making decisions in this position can be incomplete and often requires proactively interacting with multiple physicians, coders and other members of the interdisciplinary team. Requires assertive personality traits to facilitate ongoing physician communication. Decisions are solved based on a combination of professional judgment and experience. Information is analyzed in accordance with generally defined professional principles and practices. Work is guided by MIHS policies, established strategies and plans. Work is normally subject to managerial level supervision and review and evaluation of achievement objectives.