JOB SUMMARY

Performs patient record reviews to determine 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 determine 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

Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA)

Requires one of the following certifications:
Cert Cln Documentation Spec (CCDOSCP) or
Cert Cln Doc Spec Outpatient (CCDS-O) or
Cert Coding Specialist (CCS) or
Cert Doc Improv Practitioner (CDIP) or
Cert Professional Coder (CPC)

Clinical knowledge of disease process. Medical Record Review skills.

Oral and written communication skills, one to one with providers.

Knowledge of ICD-10, Complications/Comorbid Conditions and how each determines the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality

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 -
 Cert Cln Documentation Spec (CCDOCSP), Cert Clin Doc Spec Outpatient (CCDS-O), Cert Coding Specialist (CCS), Cert Doc Improv Practitioner (CDIP), Cert Professional Coder (CPC): Must have ONE of the following coding certifications:
Cert Cln Documentation Spec (CCDS) BSW code(CCDOSCP) or
Cert Cln Doc Spec Outpatient (CCDS-O) or
Cert Coding Specialist (CCS) or
Cert Doc Improv Practitioner (CDIP) or
Cert Professional Coder (CPC).

 Reg Health Info Administrator (RHIA), Registered Nurse (RN): Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).

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