Clinical Documentation Specialist

The Clinical Documentation Specialist performs concurrent & retrospective reviews of the medical record, issues physician inquiries and interacts with the medical staff and other caregivers in an effort to assure complete and accurate documentation of the patient's clinical picture and the treatment provided. The CDS acts as a liaison between coding professionals and the medical staff. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregiver and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate.

The Clinical Documentation Specialist evaluates the quality of clinical documentation to spot incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG/MS-DRG/APR-DRG’s groups and payment, address documentation issues and recognize opportunities for DRG/MS-DRG/APR-DRG’s validation. Query physicians when record information is conflicting, ambiguous or incomplete and would significantly affect coding and/or DRG/MS-DRG/APR-DRG’s assignment and/or the Severity of Illness and Risk of Mortality Scores. Act as a liaison between clinical and coding teams.