Clinical Documentation Specialist 2-4 HX

Job Summary

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and all existing comorbidities accurately reflect the patient’s clinical status and the care provided.

Job Title	Clinical Documentation Specialist 2 HX	Clinical Documentation Specialist 3 HX	Clinical Documentation Specialist 4 HX
Job Code	4970	4971	4902
Bargaining Unit	HX	HX	HX
FLSA	Non-Exempt	Exempt	Exempt
Generic Scope	Professional who applies acquired job skills, policies, and procedures to complete substantive assignments / projects / tasks of moderate scope and complexity; exercises judgment within defined guidelines and practices to determine appropriate action.	Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.	Technical leader with a high degree of knowledge in the overall field and recognized expertise in specific areas; problem-solving frequently requires analysis of unique issues/problems without precedent and/or structure. May manage programs that include formulating strategies and administering policies, processes, and resources; functions with a high degree of autonomy.
Custom Scope	Applies acquired skills and professional concepts to clinical documentation projects of small to medium size and intermediate scope and complexity. This title is bargaining unit only. There should never be an uncovered position.	Applies skills and experience as a seasoned clinical documentation specialist to projects of medium size at all levels of complexity, or portions of large projects. This title is bargaining unit only. There should never be an uncovered position.	Applies extensive knowledge of clinical documentation practices and advanced professional concepts to substantial projects of large scope and high degrees of complexity. This title is bargaining unit only. There should never be an uncovered position.
Key Resp 01	Applies acquired skills and experience in performing moderately complex reviews of patients’ medical documentation, evaluating quality, consistency, and completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).	Performs complex reviews of patients’ medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).	Conducts timely reviews of clinical documents in highly complex cases, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
Key Resp 02	Under general supervision, collaborates with clinicians, patient care staff, health information management (HIM), and coding staff, working on moderately complex cases as assigned to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.	Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.	Establishes productive working relationships with clinicians, patient care professionals, health information management (HIM), and coding staff, as well as managers in clinical, quality, and information technology departments. Works on highly complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.
Key Resp 03	Under general supervision, works with HIM coding personnel and senior staff to ensure that clinical documentation at discharge is compliant and presents an accurate reflection of the patient’s condition, treatments, and any comorbidities.	Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient’s condition, treatments, and any comorbidities. Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews.	Works closely with HIM coding staff and other personnel to ensure that all clinical documentation at discharge is fully compliant and accurately reflects the patient’s condition, treatments, and any co-morbidities. Conducts medical record reviews on specific cases involving mortalities, multiple complications, and other situations requiring secondary reviews.
Key Resp 04	Applies skills and professional concepts to analyze moderately complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement. Recommends revisions or corrections that improve compliance of clinical documentation.	Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement. Recommends timely, effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance.	Analyzes highly complex and second-level clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement. Recommends timely, effective strategies for revising DRG codes and correcting clinical documentation to resolve issues and improve compliance.
Key Resp 05	Applies acquired skills and knowledge to monitor changes and updates in regulatory requirements. Reviews assigned inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.	Monitors changes and updates in regulatory requirements for clinical documentation. Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.	Monitors, evaluates, and reports changes and updates in regulations and guidelines affecting clinical documentation. Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.
Key Resp 06	Participates in trainings to keep education current on ICD-10 coding guidelines, DRG systems, and reimbursement issues. Serves as an educational resource for physicians and other clinical staff on the roles of coding, profiling, and outcomes reporting in clinical documentation.	Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues. Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in-service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.	Maintains current knowledge of all issues related to coding, diagnosis, treatment, and reimbursement. Serves as an expert resource to all levels of clinical staff and participates in the development of curriculum for in-service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.
Education	Bachelor’s degree in nursing or related area, and/or equivalent combination of experience/training.	Bachelor’s degree in nursing or related area, and/or equivalent combination of experience/training.	Bachelor’s degree in nursing or related area, and/or equivalent combination of experience/training.
Certification			Certification as Clinical Documentation Specialist (CCDS) preferred.
Special Condition	Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have a legitimate business need to know. Ensures that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper use of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have a legitimate business need to know. Ensures that sensitive information is properly safeguarded. Follows all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.	Exercise the utmost discretion in managing sensitive information learned in the course of performing duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have a legitimate business need to know. Ensures that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper use of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.
KSA 01	Working knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems.	Thorough knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, comorbidities, discharge, and other practices that are part of effective clinical care systems.	Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems.
KSA 02	Working knowledge of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes.	Thorough understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes.	In depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes.
KSA 03	Working knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.	Thorough knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.	Advanced knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.
KSA 04	Detail oriented, with demonstrated ability to effectively manage time, see tasks through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise.	Detail oriented, with proven organizational skills and the ability to effectively manage time, prioritize tasks, and see complex projects through to completion on schedule.	Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see highly complex projects through from inception to completion on schedule.
KSA 05	Demonstrated critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess problems to develop multiple potential solutions.	Strong critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess complex problems to develop multiple potential solutions.	Advanced critical thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess highly complex problems to develop an expedient path of resolution.
KSA 06	Demonstrated interpersonal and educational skills, with the ability to collaborate effectively with clinical-care professionals, and to serve as an educational resource on coding, reimbursement, and other clinical documentation issues.	Strong interpersonal and educational skills, with the ability to collaborate effectively with clinical professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues.	Advanced interpersonal and educational skills, with the ability to collaborate effectively on highly complex projects with clinical professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues.
KSA 07	Demonstrated ability to interpret and effectively explain clinical and technical information both verbally and in writing, and to contribute to presentations, reports, and analyses as assigned.	Proven ability to interpret and effectively convey complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports.	Advanced ability to interpret and effectively convey highly complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports.
KSA 08	Demonstrated ability to work with senior staff and managers and to provide recommendations on issues of functionality, clinical quality, and efficiency.	Strong ability to work with senior staff and managers across departments and to provide advice and recommendations on complex issues of functionality, clinical quality, efficiency, and program development.	In depth ability to collaborate effectively with senior staff and management across departments and to provide counsel and guidance on highly complex issues of functionality, clinical quality, efficiency, and program development.
KSA 09	Demonstrated computer proficiency in relevant multiple technology applications.	Proven computer proficiency in relevant multiple technology applications.	Advanced computer proficiency in relevant multiple technology applications.
Environment	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)	Health care (hospital, clinical, classroom setting or similar environment as the role requires.)