Work Type: Active - Benefit Eligible and Accrues Time Off
Work Schedule: Monday - Friday
Work Hours per Biweekly Pay Period: 80
Shift Time: 8:00am-4:30pm
Location: Suntrust, US:FL:Lakeland
The Clinical Documentation Specialist reports reports to the Manager of Coding and Clinical Documentation Improvement. Concurrently reviews patient records to improve documentation to reflect accurate severity of illness and intensity of service and communicates with physicians. Works collaboratively with HIM Director, HIM Coders, and Physician Advisor to ensure accurate coding, improve the quality of DRG-related documentation, improve risk of mortality, severity of illness and case mix index. Performs other duties as assigned.
* Standard Work Duties: Clinical Documentation Specialist
- Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives.
- Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality.
- Reviews clinical issues with coding team as needed to ensure appropriate MSDRG/APR-DRG.
- Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings.
- Ensures the proper reflection of each patient's severity of illness, intensity of service, and risk of mortality.
- Serves as a resource for physicians and educates physicians on ways to improve their documentation so it more accurately reflects intensity of services/severity of illness.
- Identifies need to clarify documentation in records. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes including Present On Admission (POA), Patient Safety Indicators (PSI), and Hospital-Acquired Conditions (HAC). Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
- Assists in developing clinical documentation training for medical staff, UR/clinical resource coordinators, nursing and coders to ensure compliance with OIG, CMS, and other applicable regulations.
- Interacts with physician Advisor, HIM Director, HIM Coding staff, Compliance Officer, quality Improvement Coordinators, Department Managers, Information System staff, and Patient Financial staff on a regular basis to identify and assist in resolving documentation issues.
Qualifications & Experience
* Associate Degree
* Bachelor Degree
Education equivalent experience:
* Associates degree in Health Information Management or other healthcare related field OR Bachelor's Degree in Nursing (BSN)
* Bachelor's Degree in Health Information Management
- 5+ years' experience in either a clinical role in an acute care setting, OR, 5+ years' experience in a Health Information Management role.
- Experience with ICD-9-CM, ICD-10-CM, PCS, CPT coding and documentation review; OR experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements.
-Experience interacting with and educating medical staff and clinical support staff.
Preferred: - Experience with ICD-9-CM, ICD-10-CM and PCS, CPT coding, documentation review, DRG analysis and evaluation preferred; or experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements.
- Experience interacting with and educating medical staff and clinical support staff.
Licenses Essential: CCS/RHIT or LPN/RN
Certifications Essential: CCS/RHIT or LPN/RN
Certifications Preferred: CCDS or CDIP