COMBINED JOB DESCRIPTION/PERFORMANCE EVALUATION
JOB TITLE: Clinical Documentation Specialist
REPORTS DIRECTLY TO: HIM Director
DEPARTMENT/UNIT: Health Information Management
EFFECTIVE DATE: March 2006
BASIC PURPOSE:
The Clinical Documentation Specialist (CDS) reviews inpatient medical records while patients are still in-house (concurrent review) for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDS communicates with clinicians and physicians to ensure timely and accurate documentation and provides training and education as needed. The CDS will also perform focused reviews at the discretion of the HIM Director or Case Mgmt. Director.
WORK HOURS:
Happy Valley Hospital is a service oriented organization which operates 7 days a week, 24 hours per day. The co-worker's work schedule should reflect the working agreement made between the co-worker and the department director/manager at the time of employment. However, management retains the right to assign/reassign duties and shifts of co-workers in accordance with the needs and requirements of the health center. Work schedule may involve weekends, holidays, overtime, and low census periods.
DIMENSION:
Work is performed with minimal supervision. Progress is reviewed at critical points.
Must maintain confidential information regarding patients and staff.
Demonstrates the knowledge and skills necessary to meet individual needs based on physical, psycho-social, educational, safety, and related criteria appropriate to the age of the clients served in the assigned area.
EDUCATION, EXPERIENCE, SKILLS:
Minimum Qualifications: RN, BSN, RHIA, RHIT, or CCS or combination there of. A minimum of two years experience in nursing or other clinical area, coding, process improvement, or utilization review/case management in an acute care facility. Coding skills with experience in ICD-9CM and working knowledge of the AHA Coding Clinic (some training provided). Effective interpersonal skills in order to interact effectively with all levels of hospital personnel. Organization and prioritization skills. Effective written and verbal communications skills. Analytical skills. Proficient computer skills.
ENVIRONMENTAL DEMANDS/HAZARDOUS CONDITIONS:
Ability to lift 20 pounds. Ability to sit for prolonged periods of time. Ability to focus/read a computer screen for prolonged periods. Works inside hospital. Basic sensory skills: Visual, auditory and speech acuity.
OSHA Exposure Category III - no risk of exposure to blood or body fluids.
SECTION I: MISSION& SERVICE STANDARDS (25%)
(Rating Scale: 1-5)
Treats everyone as a valued individual.
5 4 3 2 1 1. Creates a welcoming environment, making others comfortable and giving of one's time.
5 4 3 2 1 2. Displays compassion and courtesy in all interactions.
5 4 3 2 1 3. Gives complete attention and appropriate time to the individual being served.
Seeks out and addresses customer needs.
5 4 3 2 1 1. Goes beyond expectations to satisfy the needs of our customers.
5 4 3 2 1 2. Rapidly recovers from service failures to exceed expectations of customers.
5 4 3 2 1 3. Follows up with customers and does what is promised in a timely manner.
Makes eye contact, greets and welcomes everyone.
5 4 3 2 1 1. Acknowledges everyone with hospitality and using preferred names.
5 4 3 2 1 2. Gives full and undivided attention to others.
Displays a positive presence.
5 4 3 2 1 1. Is pleasant, polite and kind.
5 4 3 2 1 2. Recognizes, accepts and supports differences in style, approach and culture; promotes
diversity.
5 4 3 2 1 3. Demonstrates an open, positive attitude toward change and participates in the change process willingly.
Keeps customers and co-workers informed on a regular basis.
5 4 3 2 1 1. Communicates thoroughly so that people know and understand what to expect.
5 4 3 2 1 2. Shares appropriate information and knowledge with co-workers and customers.
Works as a team.
5 4 3 2 1 1. Is cooperative and willing to help team members.
5 4 3 2 1 2. Demonstrates cooperation and support for the goals of the team and the organization.
5 4 3 2 1 3. Embraces and supports team decisions even if different from own.
Maintain privacy and confidentiality.
5 4 3 2 1 1. Does not access information without a legitimate "need to know".
5 4 3 2 1 2. Maintains strict confidentiality of information received and respects privacy of each
individual.
5 4 3 2 1 3. Ensures that privacy of customers is protected at all times.
Keeps a clean environment.
5 4 3 2 1 1. Ensures that all work areas (halls, restrooms, entry ways, lobbies, grounds, parking lots, etc.) are clean by picking up trash and addressing other cleanliness issues.
5 4 3 2 1 2. Maintains personal appearance by adhering to dress code policies.
Lives the Mercy Spirit.
5 4 3 2 1 1. Consistently shows commitment to mission and values of Mercy. These beliefs and values are demonstrated in day-to-day work.
5 4 3 2 1 2. Displays empathy through caring actions and gestures.
MISSION
5 4 3 2 1 1. Demonstrates conviction and commitment to Mercy's principles, values and ethical standards.
5 4 3 2 1 2. Performs in a manner consistent with the Corporate Compliance Program and Code of Conduct.
SECTION I - TOTAL POINTS ______DIVIDED BY 25 = ______
SECTION II: PERFORMANCE STANDARDS (65%)
PERFORMANCE STANDARDS: WEIGHT:
1. Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes medical necessity and capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. 30%
Performance Rating: ______X .30 = _____ points
2. Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Information will include the AHA Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills. Maintains a library of information beneficial to the work. 10%
Performance Rating: ______X .10 = _____ points
3. Keeps the CDMP database updated and current. Produces reports as requested and produces a monthly summary report of cases reviewed. 10%
Performance Rating: ______X .10 = _____ points
4. Assists the Coding Department’s co-workers when querying physicians regarding unclear documentation. 10%
Performance Rating: ______X .10 = _____ points
5. Keeps daily production of number of cases reviewed and the number of cases queries for weekly evaluation of output. 5%
Performance Rating: ______X .05 = _____ points
6. Completes Emergency Department coding and Charge Capture in accordance with coding, charging and documentation guidelines. 30%
Performance Rating: ______X .30 = _____ points
7. Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation. 5%
Performance Rating: ______X .05 = _____ points
8. Performs other duties as assigned. 5%
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