Clinical Documentation Specialist

Rochester General Hospital (RGH), a 528-bed tertiary-care facility and the flagship of Rochester General Health System, is served by more than 1,500 medical and dental staff members and more than 7,000 employees. Strong referral relationships with several regional hospitals, as well as relationships and affiliations with nationally renowned institutions including Cleveland Clinic and Roswell Park Cancer Institute, amplify the ability of RGH to provide superior clinical care to the men and women.

The Clinical Documentation Specialist facilitates and obtains appropriate clinical documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Educates members of the patient care team regarding clinical documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. The CDI Specialist should hold the following proficiencies:

**Key Responsibilities:** * Excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication. * Able to assess, evaluate, teach organize and plan. * Working knowledge of quality improvement theory and practice and medicine. * Ability and willingness to seek out and accept change and maintain positive open communication with physicians and the interdisciplinary care team members. * Reviews medical records concurrently, on a daily basis, to identify opportunities to improve the quality and completeness of clinical documentation. * Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, mid level providers, case managers, allied health professionals and nursing staff to support accurate, complete and timely documentation of clinical information. * Demonstrates knowledge of DRG payor issues and clinical documentation requirements as they relate to OIG, CMS, and State payor rules and regulations. * Coaches and educates physicians, mid level providers, case managers, allied health professionals and nurses on a daily basis to improve capture of clinical severity for the level of service rendered to patients. * Conducts follow-up reviews of clinical documentation to ensure outstanding queries for additional documentation and/or for clarification have been recorded in the patient's chart. * Captures data, such as productivity measures and tracks physician responses to Query Forms within a database. * Coordinates or conducts formal clinical documentation training for medical staff, case managers, allied health professionals, nursing and coding staff, as necessary and appropriate, as a result of internal or external audits, and to ensure compliance with OIG, CMS and TMF rules and regulations. * Identifies process improvement opportunities and supports timely and accurate capture of measurements to improve both physician and hospital outcomes as they relate to clinical documentation improvement. * Participates in conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation. Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness. Documents conference and results. * Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality. * Reviews and clarifies clinical issues in the medical record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortaliy. **Lead Responsibilities:** * Trains and audits new hires and contractors * Performs on-going audits for monitoring of CDI team * Performs monthly query audits for Compliance Committee * Provides on-going training & education of CDI team; and assists with coder discrepancy reviews * Assists in Provider education and presentations as needed * Back-up for manager duties during manager time-off * Runs daily dashboards and monthly CDI reports * Assists with validation of reports, data entry, productivity entry * Participates in peer interview of new hires * Assists manager with monitoring productivity and unit volume * Gives input to manager for reviews and PAs, unit assignments * Assists with discrepancy meetings

**Minimum Qualifications:** * RHIA/RHIT with a minimum of five years inpatient coding experience * AAS in Nursing required, BS in Nursing preferred; with a minimum of five years acute care nursing experience. * Advanced clinical expertise and knowledge of complex disease processes with a broad clinical experience in an inpatient setting. * Coding familiarity/experience in a hospital setting performing inpatient coding utilizing the AP DRG and the Medicare DRG systems preferred. * Demonstrates adaptability and self-motivation by staying current on CMS rules and regulations. * Knowledge of federal, state and private payer regulations. **Required Licensure/Certification Skills:** * If hired on or after September 1st, 213: * Must obtain eligibility to apply for CCDS certification within 24 months of hire (depending on experience level prior to hire). * Must obtain CCDS certification within 6 months after achieving eligibility requirements. * If hired prior to September 1st, 213: * Must obtain eligibility to apply for CCDS certification within 24 months (2 years of experience as CDI Specialist). * Must obtain CCDS certification within 12 months after achieving specific requirements. * RHIT/RHIA, CCS preferred. * For nursing-prepared candidates: * RN license in New York State required.