Clin. Documentation Specialist - Westchester Medical Center

Job Summary: Provides clinically based concurrent review of patient medical records to ensure documentation accurately reflects the level of clinical services, severity of illness and specificity of care. Responsibilities require interaction with physicians, nursing staff, medical records coding staff, compliance specialists and other healthcare providers to ensure that clinical information in the medical record is present and accurate so that the appropriate utilizations, clinical severity, outcomes and quality are captured for the level of service rendered and ensure compliant reimbursement of patient care services. Does related work as required.

Responsibilities:

Reviews and analyzes patient medical record to assess and procure accurate and complete documentation of patient diagnoses and procedures.

Notifies attending physician and house staff officers or other disciplines promptly of documentation requiring clarification.

Conducts follow-up reviews to ensure points of clarification have been addressed and recorded in the medical record and maintains an ongoing record of the results of each chart review, including responses to each intervention.

Compiles and documents chart findings in dedicated CDI database on a daily basis.

Translates diagnostic phrases utilized by healthcare providers into coded form and interacts with the healthcare provider to ensure that the terms have been translated correctly.

Maintains awareness of the continual changes in federal and state regulations for prospective payment;

Communicates with and educates members of the patient care team and clinical documentation team on an ongoing basis.

Serves as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information.

Facilitates ongoing education of staff in relation to chart documentation improvement techniques and practices.

Assists as necessary with review of the medical record post discharge to determine coding status;

Completes timely retrospective review for unanswered queries.

Facilitates complete discharge summaries.

Recommends strategies for improving record keeping processes.

Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage.

May review overall quality and completeness of coding by reconciling differences in the MS-DRG/APR-DRG assignment through comparison and analysis of the coding summary and CDI patient summary against the medical record documentation.

Qualifications/Requirements:

Experience: Minimum of three years of healthcare experience required, strong medical/surgical background. Experience with Coding/DRG, billing, auditing and reimbursement is preferred. Clinician preferred with a CDIP/CCDS/CCS credential.

Education: Bachelor's degree in a healthcare field, required.

Licenses / Certifications: At least one of the following active certification/licenses required:

· CDIP: Clinical Documentation Improvement Practitioner

· CCDS: Certified Clinical Documentation Specialist

· CCS: Certified Coding Specialist, or equitable coding credential

Preferred minimum requirement:

· RHIT/RHIA: Registered Health Information Technician/Administrator

· RN: Current/active license as a registered nurse in the state of residence or current /active RN license with the ability to transfer license to state of residence within three months of start

Other: Thorough knowledge of clinical documentation strategies and hospital-acquired conditions/present on admission and core measures; through knowledge of medical terminologies, procedures and applicable laws to collect and evaluate medical documentation; thorough knowledge of ICD-9, ICD-10, MS-DRGs, documentation compliance standards and coding principles and guidelines; good knowledge of healthcare delivery system, utilization review, case review and quality improvement practice and theory; skill in reviewing charts and utilizing electronic medical record and clinical documentation program; ability to communicate effectively and diplomatically within a multi-functional team which includes physicians, other members of the allied healthcare team and HIM coders; strong organizational, planning and observation skills; attention to detail; analytical-critical thinking and problem solving skills; excellent written and verbal communication; excellent computer skills and knowledge of software for database maintenance and electronic health record storage; ability to establish and maintain effective working relationships with all levels of medical, nursing, and non-professional staff; resourcefulness; flexibility; assertiveness; initiative; tact; creativity; thoroughness; sound professional judgment; physical condition commensurate with the demands of the position.

Special Requirements: High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers. MS Office (Word, Excel, Outlook, and PowerPoint) knowledge is expected. Chart review experience required. Cerner Millennium Electronic Medical Record and 3M CDI Software experience is preferred. Regulatory background and DRG reimbursement knowledge preferred.

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