JOB SUMMARY

Performs patient record reviews to establish complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Present queries to physicians when needed to clarify ambiguous or incomplete documentation. Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.

ESSENTIAL FUNCTIONS OF THE ROLE

• Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
• Performs review of record to establish complete, accurate documentation of patient condition and treatment. When appropriate, update working DRG.
• Demonstrates ability to recommend proficient query\ies to practitioners or support staff regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed. Appropriately escalates provider non-responses or inappropriate responses for reconciliation.
• Collaborates with Health Information Management coders, other Clinical Documentation Improvement Specialists and others to reconcile potential documentation and coding opportunities. This might include analyzing working versus final coded DRG
• Collaboratively works with interdisciplinary teams including, but not limited to physicians, mid- level providers, nurses, Patient Safety staff and Health Information Improvement teams.
• Develops and/or provides ongoing education and information regarding documentation opportunities to practitioners, Health Information Management Coders, and other Clinical Documentation Improvement Specialists. Promotes related education to others such as allied health professionals, Administration, Utilization Review, Comprehensive Care specific to documentation and its effect on SOI, ROM, CMI, reimbursement and data reporting.
• Formulates, interprets, and analyzes data relative to opportunities to improve documentation practices. Prepares CDI metric based documents for senior leadership and medical staff groups/divisions.
• Serves on internal Hospital committees relating to CDI, CMI and ELOS along with functioning as a subject matter expert and problem solver.
• Works directly with physicians and is a liaison for physician and administrative meetings. Train and audits BSWH CDI specialists.
• Performs other position appropriate duties as required in a competent, professional and courteous manner.

KEY SUCCESS FACTORS

• Clinical knowledge of disease process.
• Medical Record Review skills.
• Knowledge of medical necessity rules.
• Use of Diagnosis Related Grouper and ICD-10 coding tools.
• Oral and written communication skills, one to one with providers.
• ICD-10 Coding Guidelines.
• Use computer programs associated with job code as well as all Microsoft Office programs.
• Ability to present information to a group.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level

• QUALIFICATIONS
  
  - EDUCATION - Masters'
  
  - EXPERIENCE - 5 Years of Experience
  
  - CERTIFICATION/LICENSE/REGISTRATION -
  Registered Nurse (RN)
  • Cert Clinic Documentation Spec (CCDOCSP)
  • Cert Coding Specialist (CCS)
  • Cert Doc Improv Practitioner (CDIP)
  • Cert Professional Coder (CPC)
  • Cert Prof Coder - Apprentice (CPC-A)

Must be a Registered Nurse (RN) AND have at least one of the following coding certifications:

CCS or CCDOCSP or CDIP or CPC or CPC-A.