Wellstar Health System
Clinical Doc Spec PRN – Wellstar Health System
Location: Atlanta, GA
Work Shift Day (United States of America)
Job Summary The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The PRN CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. PRN CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.
Core Responsibilities And Essential Functions
Review clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicate identified opportunities to the physician.
Facilitate appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff.
Conduct timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
Perform concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes.
Submit documentation clarification queries as appropriate to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
Ensure queries are compliant, grammatically correct, concise, and free of typographical errors.
Provide appropriate follow-up on all queries and expedite escalation when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process.
Reconcile all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
Maintain required daily/weekly/monthly metrics and meet productivity standards.
Participate in required departmental meetings, conference calls and presentations.
Adhere to departmental policies and procedures.
Submit ideas to improve workflow and increase productivity/efficiency of the team to the CDI Leadership Team and perform any other duties as assigned.
Maintain knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
Maintain knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
Review quarterly Coding Clinic changes/summaries and follow appropriate required changes to processes.
Participate in assuring hospital compliance with Federal and State regulatory requirements.
Educate members of the patient care team, including medical staff, on documentation guidelines on an ongoing basis.
Ensure the accuracy and completeness of clinical information used for measuring and reporting physician, hospital, and regulatory outcomes.
Review data and trends to identify additional opportunities, provide input to core measure and other quality data initiatives, and identify and participate in opportunities to improve documentation, Epic, and quality of care initiatives.
Perform other duties as assigned and comply with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum Education
Associates Nursing or Bachelors Health Science or Bachelors Nursing or Doctorate Medicine
Required Minimum Licenses And Certification(s)
Cert Coding Spec or Cert Prof Coder or Reg Health Information Admin or Reg Health Information Tech or Reg Nurse (Single State) or RN – Multi‑state Compact
Cert Document Improvement Prac‑Preferred or Cert Clin Document Specialist‑Preferred
Required Minimum Experience
Minimum 2 years of working in an acute care setting as a Clinical Documentation Specialist (CDS)
Minimum 5 years of healthcare experience
Epic and Solventum/3M 360 Encompass experience is required
Prior experience of working as a CDI/Coding auditor is preferred
Prior experience of working in inpatient case management or utilization review is preferred
Required Minimum Skills
Strong understanding of disease processes, clinical indications and treatments, and provider documentation requirements to reflect severity of illness, risk of mortality and support accurate coding and billing according to Medicare, Medicaid, and commercial payor rules.
Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR).
Epic and Solventum/3M 360 Encompass experience is required.
Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives.
Excellent communication skills, employing tact and effectiveness.
Demonstrate effective communication skills and collaborate with medical staff, clinical departments, and key facility leadership team members.
Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives.
Excellent problem‑solving skills, with the ability to recommend and implement practical and efficient solutions.
Must have proficient computer skills in Microsoft Apps such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions.
Drives optimal use of the CDI technology tool and reporting capabilities.
Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.
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Work Shift Day (United States of America)
Job Summary The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The PRN CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. PRN CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.
Core Responsibilities And Essential Functions
Review clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicate identified opportunities to the physician.
Facilitate appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff.
Conduct timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
Perform concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes.
Submit documentation clarification queries as appropriate to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
Ensure queries are compliant, grammatically correct, concise, and free of typographical errors.
Provide appropriate follow-up on all queries and expedite escalation when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process.
Reconcile all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
Maintain required daily/weekly/monthly metrics and meet productivity standards.
Participate in required departmental meetings, conference calls and presentations.
Adhere to departmental policies and procedures.
Submit ideas to improve workflow and increase productivity/efficiency of the team to the CDI Leadership Team and perform any other duties as assigned.
Maintain knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
Maintain knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
Review quarterly Coding Clinic changes/summaries and follow appropriate required changes to processes.
Participate in assuring hospital compliance with Federal and State regulatory requirements.
Educate members of the patient care team, including medical staff, on documentation guidelines on an ongoing basis.
Ensure the accuracy and completeness of clinical information used for measuring and reporting physician, hospital, and regulatory outcomes.
Review data and trends to identify additional opportunities, provide input to core measure and other quality data initiatives, and identify and participate in opportunities to improve documentation, Epic, and quality of care initiatives.
Perform other duties as assigned and comply with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum Education
Associates Nursing or Bachelors Health Science or Bachelors Nursing or Doctorate Medicine
Required Minimum Licenses And Certification(s)
Cert Coding Spec or Cert Prof Coder or Reg Health Information Admin or Reg Health Information Tech or Reg Nurse (Single State) or RN – Multi‑state Compact
Cert Document Improvement Prac‑Preferred or Cert Clin Document Specialist‑Preferred
Required Minimum Experience
Minimum 2 years of working in an acute care setting as a Clinical Documentation Specialist (CDS)
Minimum 5 years of healthcare experience
Epic and Solventum/3M 360 Encompass experience is required
Prior experience of working as a CDI/Coding auditor is preferred
Prior experience of working in inpatient case management or utilization review is preferred
Required Minimum Skills
Strong understanding of disease processes, clinical indications and treatments, and provider documentation requirements to reflect severity of illness, risk of mortality and support accurate coding and billing according to Medicare, Medicaid, and commercial payor rules.
Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR).
Epic and Solventum/3M 360 Encompass experience is required.
Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance improvement initiatives.
Excellent communication skills, employing tact and effectiveness.
Demonstrate effective communication skills and collaborate with medical staff, clinical departments, and key facility leadership team members.
Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives.
Excellent problem‑solving skills, with the ability to recommend and implement practical and efficient solutions.
Must have proficient computer skills in Microsoft Apps such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions.
Drives optimal use of the CDI technology tool and reporting capabilities.
Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.
#J-18808-Ljbffr