Clinical Documentation Specialist

Job Number 54769
Posted 5/17/2018
Account Inland Hospital
Department HIMS
Location Inland Hospital, ME 04901
Schedule Regular Full-time
Shift Day
Hours 8-4:30
Job Details

Review Listed Prequalification's Below


The Clinical Documentation Specialist is responsible for concurrent review of the clinical documentation in the medical records. The position queries the medical staff and other care givers as necessary using prompters and verbal communication to obtain accurate and complete documentation, which appropriately supports the severity of patient illness and the intensity of service.

The incumbent performs duties and tasks in accordance with performance standards established for the job. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position. In addition, the incumbent conducts all job responsibilities according to the Mission and Values of the facility.


1. Assigns a working DRG for all selected admissions

a. Identifies and records principle diagnoses, secondary diagnoses, and procedures

b. Works in collaboration with the physician, nurse, patient care coordinator, and Medical Records coder, as appropriate

c. Attends daily Interdisciplinary Team Meetings

d. Works closely with Case Management in-patient admission process, continued stay reviews and discharge status documentation

2. Initiates the tracking process and identifies quality indicators

a. Conducts initial concurrent and extended stay reviews for all selected admissions

b. Identifies co-morbidities and complications along with severity of illness and risk of mortality documentation appropriately

c. Captures all potential secondary and/or chronic condition diagnoses

d. Documents finding on the DRG worksheets and tracking tools, keeping all documentation and tracking up to date

3. Queries care givers via verbal or written communication as necessary to obtain accurate and complete documentation

a. Identifies need to clarify documentation in records

b. Initiates communication with physician, coding and clinical staff regarding documentation and any identified coding/documentation processes, issues, trends or improvement opportunities

c. Identifies and utilizes appropriate query tools to capture documentation that accurately supports a patient's severity of illness

d. Emails query to appropriate provider

e. Follows-up on queries daily until answered

f. Completes tracking tool with query information

4. Tracks progress of the Clinical Documentation Improvement Program

a. Identifies appropriate monitoring tools

b. Interprets tracking information

c. Reports findings to CDI committees, EMHS Revenue Cycle, and department managers accordingly.

d. Coordinates and facilitates communication between Medical Records and Utilization Review, Case Management, Providers and coders Managed Care

5. Undergoes continual self-evaluation

a. Meets CDI program quality and productivity guidelines

b. Coder feedback on completed worksheets and individual DRG tracking system

c. Works identified DRG mismatches with the coder when identified

d. Performs Clinical Validation of each documented diagnosis

e. Discusses any issues or concerns with immediate Supervisor and EMHS Revenue Cycle

6. Assists in the development and distribution of physician profiling reports to include but not limited to MS-DRG, APR-DRG, Severity of Illness/Risk of Mortality, Hierarchical Condition Category, Case Mix Index, and query response

7. Provides information and education as necessary to physicians and ancillary staff to include documentation and coding updates, report cards, tracking forms, analysis reports, etc.

8. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements monitors changes in laws, regulation, rules, coding guidelines

9. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements.

10. Monitors changes in laws, regulations, rules, coding guidelines and code assignments that affect clinical documentation and financial reimbursement and educates staff accordingly.

11. Coordinates and maintains all elements of a Clinical Documentation Improvement Program in conjunction with EMHS Revenue Cycle CDI Staff.

12. Meet CDI program objectives, goals, mission and vision statements, along with analytic reporting and scorecards.

13. Other duties as assigned


Work is performed in an office setting and/or patient care areas.


• Work is performed during regular work hours, but may require overtime and/or weekend hours to meet deadlines

• Work in varying degrees of temperature (heated or air conditioned)

• Work under extreme pressures

• Position requires sitting for approximately 4-6 hours per day and walking for 2 hours per day

• Position requires light to moderate work with minimal weight to lift and carry

• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing

• Frequent close eye work (computers, typing, reading, writing)




Knowledge of care delivery documentation systems and related medical record documents is recommended. Strong computer skills, familiarity with web-based computer programs are preferred. Knowledge of age-specific needs and the detailed elements of disease processes and related procedures preferred. Excellent written and verbal communication skills to interact effectively with individuals in all levels of the hospital system are highly recommended. Strong critical thinking skills and ability to work independently in a time-sensitive environment.


Licensure and registration as a Registered Nurse in the State of Maine or current Medical Coding Certificate and/or degree (i.e. RHIT, RHIA, CCS, or other) or a minimum of 5 years clinical experience in a related medical field/facility is required.


A minimum of 5 years of experience in an acute care hospital setting is required. Knowledge of ICD-10-CM and ICD-10-PCS coding and coding guidelines is essential.

Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.