Howard University Hospital | Washington, DC

    Clinical Documentation Specialist

    Job Title
    Clinical Documentation Specialist
    Job ID
    27652369
    Location
    Washington,  DC 20060
    Other Location
    Description

    With over 150 years of caring for our community and each other in the Washington DC area, Howard University Hospital has a world-renowned reputation for high-quality, patient-centric care. Howard University Hospital is the nation’s only teaching hospital located on the campus of a Historically Black University and has created a superior learning environment, with groundbreaking research and positive patient outcomes.

    Howard University Hospital seeks to hire a Clinical Documentation Specialist who will embrace our reach and historic tradition of excellence. If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.

    The Clinical Documentation Specialist: 

    • Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG-based payer (Medicare, Medicaid, Blue Cross, etc.) 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 will also perform focused reviews at the discretion of the HIM Director or the Chief Medical Officer.
    • Conducts retrospective reviews of discharged records for accuracy of final DRG assignment consistent with clinical documentation.
    • Educates all members of the patient care team on an ongoing basis.
    • Performs daily concurrent review of records on assigned nursing unit to identify opportunities to obtain accurate documentation and reflect the severity of illness.
    • Assigns a working DRG using Cooperating Parties coding guidelines and Physician Query Tracking software or other developed methods.
    • Verifies presence of clinical documentation supporting patient’s severity of illness equating to intensity of service.
    • Assures presence of continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress” of the patient.
    • Facilitates completion of discharge summaries in promotion of post-acute care to facilitate orderly handoff to patient’s primary care physician.
    • Queries physicians on a concurrent basis to ensure accurate documentation is recorded in the medical record.
    • Follows-up on physician queries to ensure appropriate documentation is recorded in the medical record prior to coding and billing.
    • Works with Coding staff to clarify documentation, ensuring that the most accurate DRG has been assigned for billing purposes.
    • Identifies missed opportunities related to clinical documentation and coding guidelines.
    • Follows up with required documentation that results in the accurate capture of the severity and/or mortality indices.
    • Keeps daily production of cases reviewed and queried, using the Physician Query Tracking software.
    • Enters physician responses using the Physician Query Tracking software for monitoring of trends, training opportunities, compliance, and response time.
    • Assists in the education of physicians and clinicians regarding the importance of Clinical Documentation Improvement (CDI).
    • Refers quality issues to the Director of CDI/HIM.
    • Participates in departmental quality assurance activities.
    • Assumes other duties and responsibilities that are related and appropriate to the position and area. The
      above responsibilities are a general description of the level and nature of the work assigned to this
      classification and are not to be considered as all-inclusive.

     A qualified candidate will possess: 

    • ​​​​​​Bachelor Degree in Health Information Technology, Health Sciences or graduate from an accredited school of Nursing or Medicine; Registered Nurse, BSN or MD preferred. (If degree is in Nursing, a minimum of five (5) years of direct clinical nursing experience.)
    • Graduate of an accredited Health Information Management Program with credentials as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
    • Minimum four (4) years of recent working experience with ICD-10-CM Inpatient Coding/DRG assignment required. Minimum 1-year experience as inpatient CDS in an acute care hospital is highly recommended.
    • One or more of the following professional certifications in medical coding or clinical documentation improvement preferred: Certified Coding Specialist (CCS) (from AHIMA), Certified Clinical Documentation Specialist (CCDS) (from ACDIS), Clinical Documentation Improvement Practitioner CDIP) (from AHIMA).
    • Utilization Review or Case Management experience preferred.

    At Howard University Hospital our job is to care for you. We do this by offering:

    • Work-life balance.
    • Recognition and rewards for professional expertise.
    • Competitive, comprehensive benefit plans offered (including health, disability, vacation, sick leave, and 403B retirement plan).

    COVID-19 Vaccination 

    Howard University Hospital requires all external applicants to be fully vaccinated for COVID-19 before commencing employment.  External Applicants may be required to furnish proof of vaccination and, if offered, may elect to be vaccinated at a designated Howard University Hospital location. 
     
    Must be able to stand, walk, sit, lift, climb, stoop, kneel, crouch, crawl,  bend,  pull, push, reach,  write, type, file, speak, hear, see (depth perception, color vision), calculate, compare, edit, evaluate, interpret and organize for extended periods of time.

    Required Skills

    MINIMUM REQUIREMENTS:

    Health Information Professionals:
    Graduate of an accredited Health Information Management Program with credentials of a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
    Four (4) years of recent working experience with ICD-9-CM and/or ICD-10 Inpatient Coding/ORO assignment highly recommended.
    Minimum of one (1) year recent experience as inpatient CDS in acute care hospital highly recommended.
    One or more of the following professional certifications in medical coding or clinical documentation improvement desirable:
    Certified Coding Specialist (CCS) (from AHIMA)
    Certified Clinical Documentation Specialist (CCDS) (from ACDIS)
    Clinical Documentation Improvement Practitioner (CDIP) (from AHIMA).

    Nursing Professionals:
    Graduate from an accredited school of Nursing; Registered Nurse, BSN preferred.
    Minimum of five (5) years of direct clinical nursing experience.
    Minimum of one (1) year experience as inpatient CDS in acute care hospital highly recommended.
    Utilization Review or Case Management experience preferred.
    One or more of the following professional certifications in medical coding or clinical documentation improvement desirable:
    Certified Coding Specialist (CCS) (from AHIMA)
    Certified Clinical Documentation Specialist (CCDS) (from ACDIS)
    Clinical Documentation Improvement Practitioner (CDIP) (from AHIMA)

    Medical School Graduates:
    Graduate of an accredited Medical School with minimum 4 years of medical science education.
    Minimum of one (1) year experience as inpatient CDS in acute care hospital highly recommended.
    One or more of the following professional certifications /diploma in medical coding or clinical documentation improvement desirable:
    Diploma in medical coding
    Certification in medical coding (CCS from AHIMA)
    CDIS (from ACDIS) or CDIP (from AHIMA)
    Optional Skills

    Bachelor Degree in Health Information Technology, Health Sciences or graduate from an accredited
    school of Nursing or Medicine; Registered Nurse, BSN or MD preferred. (If degree is in Nursing, a
    minimum of five (5) years of direct clinical nursing experience.)
    Graduate of an accredited Health Information Management Program with credentials as a Registered
    Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
    Minimum four (4) years of recent working experience with ICD-9-CM Inpatient Coding/DRG assignment
    required. Minimum 1 year experience as inpatient CDS in acute care hospital highly recommended.
    One or more of the following professional certifications in medical coding or clinical documentation
    improvement preferred: Certified Coding Specialist (CCS) (from AHIMA), Certified Clinical
    Documentation Specialist (CCDS) (from ACDIS), Clinical Documentation Improvement Practitioner
    (CDIP) (from AHIMA).
    Utilization Review or Case Management experience preferred.

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