The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical documentation in the inpatient medical record with the goal to obtain the most accurate and complete physician documentation that appropriately supports the severity of a patient’s illness, mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via written and/or verbal communications for clarification of clinical documentation. He/she works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. In collaboration with the RN CCs team will Provides ongoing education related to documentation requirements and opportunities to all providers requirements and opportunities to all providers. Will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency
• Performs admission reviews within 24 to 48 hours for patient populations to facilitate
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results,
• Queries physicians and non-physician providers verbally and in writing daily according to
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis,
• Provides education to physicians in a one to one setting regarding documentation specificity and the
• Utilizes medical staff established criteria for complications to assist in appropriate documentation
• Collaborates with clinical coordinator and RN CCS with the coding staff and provides clinical
• Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.??
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or p patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization

Minimum Qualifications

Education
• Minimum 2 Year / Associate Degree Graduate of an approved school of nursing, Bachelor’s degree preferred
• Preferred 4 Year / Bachelors Degree

Experience
• Three (3) years of medical/surgical nursing experience with at least one year of Billings Clinic experience preferred but not required.

Certifications and Licenses

• Current Montana license as an RN or ability to obtain
• Certified Coding Specialist CCS, Within 2 years of hire
• Certified Clinical Documentation Specialist (CCDS) Within 2 years of hire
• Certified Documentation Improvement Practitioner (CDIP), Within 2 years of hire
• Certified Professional Coder (CPC), Within 2 years of hire

Or an equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered. Employees that require a licensed or certification must be properly licensed/certified and the licensure/certification must be in good standing.