Clinical Documentation Specialist - FT - Day Shift
: Job Details :

HOURLY RANGE: $42.300 - $57.147DISTINGUISHING FEATURE OF THE CLASS: The work involves ensuring the overall quality and completeness of clinical documentation for patients at the Erie County Medical Center Corporation (ECMCC).The incumbent facilitates modifications to clinical documentation to support and optimize reimbursement and ensure clinical severity is captured for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) based payer.The work is performed under the general supervision of the Director of Clinical Coding and Record Quality Management.Supervision may be exercised over professional, technical or clerical staff.Does related work as required.TYPICAL WORK ACTIVITIES:

• Reviews inpatient medical records for identified payer populations, such as Medicare, Medicaid, or health insurances, as directed on admission and throughout hospitalization and occasionally on post discharged records;
• Analyzes clinical status of patient, current treatment plan and past medical history; identifies potential gaps in physician documentation;
• Communicates with attending physicians and residents to validate observations and assists with collecting additional and/or more specific documentation;
• Works closely with Coding Staff to assure documentation of discharge diagnoses and co-existing co-morbidities are a complete reflection of the patient's clinical status and care while ensuring coding guidelines are followed and diagnoses are clinically supported;
• Ensures timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes;
• Develops and implements plans for education of physicians, nursing and other clinical staff; educates staff on documentation improvement;
• Collaborates with physician administrators to design and implement specific tools to support medical record physician documentation;
• Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation;
• Establishes and monitors programs for quality control of accuracy, completeness and timeliness of documentation;
• Analyzes, interprets and reports findings of program impact to management, physicians, patient care team, coding staff and other clinical staff;
• Facilitates multidisciplinary team efforts for clinical documentation improvement;
• Demonstrates and applies basic knowledge of the American Health Information Management Association (AHIMA) Standards of Coding for evaluation of medical record documentation;
• Meets established productivity targets for record review.

FULL PERFORMANCE KNOWLEDGES, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS: Good knowledge of research methods and procedures used in conducting medical data analysis; Good knowledge of medical terminology; Good knowledge of regulatory agency requirements pertaining to hospital medical records; Working knowledge of the AHIMA Standards of Coding; Working knowledge of program planning and evaluation techniques; Ability to retrieve and analyze data and prepare reports; Ability to communicate effectively both orally and in writing; Ability to establish and maintain effective working relationships with a diverse constituency; Ability to train others; Tact; Initiative; Confidentiality; capable of performing the essential functions of the position with or without reasonable accommodation.MINIMUM QUALIFICATIONS:

Possession of a Bachelor's Degree in Nursing and three (3) years of experience in inpatient medical/surgical or critical care; or

Possession of an Associate's Degree in Nursing and five (5) years of experience in inpatient medical/surgical or critical care; or

An equivalent combination of training and experience as defined by the limits of (A) and (B).

SPECIAL REQUIREMENT:Possession of a license and current registration to practice as a Registered Nurse in the State of New York at time of appointment and maintenance throughout duration of appointment.NOTE 1: Your degree must have been awarded by a college or university accredited by a regional, national, or specialized agency recognized as an accrediting agency by the U.S. Department of Education/U.S. Secretary of Education.If your degree was awarded by an educational institution outside the United States and its territories, you must provide independent verification of equivalency.A list of acceptable companies who provide this service can be found on the Internet at must pay the required evaluation fee.NOTE 2: Verifiable part-time and/or volunteer experience will be pro-rated toward meeting full-time experience requirements.