Clinical Documentation Specialist
2. Re-reviews inpatient health records while patients are in-house, concurrently, for proper documentation. Follow-up re-review will be done every two to three days until the patient is discharged to assign a working or final DRG upon patient discharge.
3. Initiates and completes queries regarding missing, unclear or conflicting documentation in the health record required for quality patient care and accurate DRG assignment concurrently.
4. Interacts with ancillary departments to obtain missing information needed to properly support billing accounts based on documentation in the medical record.
5. Attends daily case management meetings.
6. Partners with HIM coding professionals to ensure accuracy of diagnosis and procedural data and completeness of supporting documentation to ensure documentation of discharge diagnoses and any co-morbidities.
7. Educates providers one-on-one in understanding the clinical documentation requirements for diagnosis capture both formal and informal. This includes nursing and other clinical staff regarding clinical documentation improvement and the need for accurate and completed documentation in the health record.
8. Identifies clinical documentation issues and works with ancillary departments to resolve issues and notify appropriate leadership.
9. Maintains clinical database updated and current. Produces reports as requested and produces monthly summary reports of cases reviewed. Reviews results for patterns, specific clinical issues and overall issues for noncompliance or possible educational needs.
10. Performs concurrent record reviews on all selected admissions and documents findings.
11. Serves as a team member and assists in recovery audit process reviews.
12. Serves as a resource for physicians to help link ICD-9 and ICD-10 CM coding guidelines and medical terminology to improve accuracy of documenting patient severity of illness, risk of mortality and final code assignment.
13. Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals.
14. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
15. Adheres to all compliance guidelines and maintains strictest confidentiality.
16. Supportive of the compliance program set forth by IASIS and demonstrated by:
- Upholding the Standards of Conduct and Corporate Compliance.
- Adheres to and helps to enforce all compliance policies relevant to his/her area.
- Assures timely compliance education as requested by the Regional Compliance & Safety Officer and/or through corporate initiatives.
- Sets an example to all staff in their daily activities.
17. Other duties as assigned.
18. Consistently supports and communicates the Mission, Vision and Values of SJMC
19. Follows the SJMC guidelines related to the Health Insurance Act of 1996 (HIPPA) designed to prevent and detect unauthorized disclosure of protected health information (PHI).
20. Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non punitive environment.
21. Maintains and uses proficiency in communication skills, both written and verbal.
- Five years of experience in an acute care setting.
- Knowledge of care delivery documentation systems and related medical record documents.
- Prior experience in clinical documentation improvement programs preferred.
- RN License, preferred, CCDS certification preferred
- RNs with case management experience preferred
- RNs with utilization review experience preferred
- Bachelor of Science degree in nursing, preferred.
- Excellent communication skills both verbal and written
- Good interpersonal skills
- Able to establish good customer relationships with trust and respect
- Computer skills: navigation and edit resolution through various Web based systems; Proficient use of Microsoft office, specifically excel, Word, Outlook
- Self directed, motivated and a positive attitude
- Must exhibit excellent organizational skills
- Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs preferred
- Understanding of the coding classification systems, ICD-9, ICD-10, CPT, HCPCS
- Clinical knowledge to read and analyze a patient’s health record
- Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes