CLINICAL DOCUMENTATION SPECIALIST

1. Collaborate with physician, physician extender, nurse, case manager, and Health Information Management coder to identify areas for improved physician documentation. 2. Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings on worksheets, denoting all key information utilized in the tracing process. 3. When a need to clarify documentation in the records is identified, individual must utilize assertive communication skills to guide physician, case manager, or other healthcare professionals to make changes as appropriate to clarify documentation. Must work collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements. Follow thru to obtain response to physician queries. 4. Utilize monitoring tools to track the progress, monitoring reports and data. Communicate findings with appropriate management staff. Able to identify areas of focus through report analysis. 5. Assist in the development of physician query response reports. Provides education and in-services as necessary to physicians and ancillary staff.