In an environment of continuous quality improvement, the Clinical Documentation Specialist is responsible for reviewing physician documentation practices to comply with governmental regulations for standardized patient care and quality of care core measure indicators.  In this role, the Clinical Documentation Specialist will complete chart reviews and facilitate documentation improvement through communication with the physicians in order to maintain compliance requirements for data abstraction, analysis, and reporting. Exhibits the MHS Standards of Excellence and exercises strict confidentiality at all times.

 

Job Functions:

Conducts concurrent and retrospective documentation review. Assesses learning needs in order to plan and participate in education programs for physicians, coding specialists and clinical staff. Maintains responsibility/accountability for professional development and maintaining licensure. Functions as a liaison person in analyzing and evaluating physician documentation practices. Takes responsibility to identify barriers to complete timely physician documentation and promote improvements in work processes Utilizes computer systems effectively including 3M encoder, Meditech, Chartmaxx, Excel Spreadsheet, vendors, software abstracting tools, and other systems as appropriate. Assumes all other duties and responsibilities as necessary.