Clinical Documentation Specialist - West Allis

The primary responsibilities of a Clinical Documentation Specialist at Aurora Medical Center West Allis involve concurrent reviews of clinical documentation, querying medical staff to ensure accurate documentation, conducting initial reviews for patient admissions, and collaborating with healthcare professionals to capture comprehensive records. You'll also educate medical staff on documentation standards and track quality indicators.

To qualify for the Clinical Documentation Specialist role at Aurora Medical Center West Allis, candidates must hold a Bachelor’s Degree in Nursing and possess an active Registered Nurse license. Additionally, a minimum of three years of experience in an acute inpatient setting is required, alongside strong analytical and interpersonal communication skills.

The Clinical Documentation Specialist at Aurora Medical Center West Allis contributes to patient care by ensuring that the clinical documentation in medical records accurately reflects the severity of illnesses. This role involves identifying key diagnoses, facilitating communication among the healthcare team, and promoting proper coding practices that ultimately support patient care quality and reimbursements.

Aurora Medical Center West Allis offers a comprehensive suite of benefits to Clinical Documentation Specialists, including competitive compensation, paid time off, health and welfare benefits, retirement plans with employer match, educational assistance programs, and family-friendly benefits like adoption assistance and paid parental leave.

The work schedule for a Clinical Documentation Specialist at Aurora Medical Center West Allis is a full-time position structured for 40 hours per week, with a hybrid format that requires working three days onsite and two days remotely during standard business hours, Monday through Friday.

When answering this question, consider highlighting specific experiences where you managed clinical documentation, pointing out how your efforts improved patient care quality. Include details about the types of diagnoses and procedures you handled to demonstrate your hands-on experience.

To ensure accuracy in clinical documentation, emphasize your attention to detail, your familiarity with coding and reimbursement policies, and your process for reviewing data against patient records. Discuss any tools or methods you use to maintain accuracy, such as double-checking information and conducting audits.

Share the strategies you employ to promote open dialogue with physicians and staff, such as active listening, maintaining a respectful tone, and leveraging educational resources. You might also mention steps you take to foster a collaborative environment that encourages continuous improvement in documentation practices.

In such situations, discuss your approach to follow-up communication, which can include providing additional context or the implications of missing documentation. Emphasize the importance of diplomacy and patience in ensuring that queries are addressed promptly and effectively.

Emphasize the importance of critical thinking in evaluating clinical data, identifying discrepancies, and determining the need for further documentation. Illustrate with an example of how critical thinking allowed you to resolve an issue or enhance the accuracy of patient records.

Discuss specific challenges you have encountered, such as misunderstandings with medical staff or changes in documentation guidelines. Explain the steps you took to overcome these challenges, focusing on your problem-solving skills and proactive approach.

Highlight the significance of documenting co-morbidities as they impact the severity of patient illness and reimbursement rates. Explain how this documentation can affect care planning and outcomes, and discuss methods you use to capture and communicate this important information.

Share details about specific monitoring tools you have used to track documentation practices and improve quality. Discuss how you have leveraged these tools to analyze data trends and ensure compliance with documentation standards.

Discuss your commitment to ongoing education through professional organizations, attending workshops, and consuming relevant literature to keep abreast of changes in clinical documentation standards. Explain how you apply this knowledge to your work at Aurora Medical Center.

Convey your passion for ensuring high-quality patient care and your desire to make a meaningful impact within the healthcare system. Discuss specific elements of the work that inspire you, like the opportunity to collaborate with healthcare professionals and educate staff on documentation best practices.