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Clinical Documentation Specialist, Acute Rehabilitation
3 months ago
Organization:
CPMC-California Pacific Med Center Davies
Position Overview:
Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care.
Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.
Job Description:These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job.
Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).
JOB ACCOUNTABILITIES:CLINICAL DOCUMENTATION:
- Identifies patient medical records for review prioritized by length of stay, diagnoses, and other defined criteria and/or strategies.
- Reviews and evaluates the accuracy and completeness of clinical documentation to ensure accurate reflection of patient's severity of illness and quality of care rendered to enable the assignment of appropriate Diagnosis Related Groups (DRGs).
- Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to query for missing, unclear and conflicting documentation, and proactively follows-up as needed to ensure a high rate of query response.
- Reviews records to ensure compliance with coding and reimbursement requirements, identifies and records principal and secondary diagnoses, principal procedure and assigns a working DRG.
- Serves as a resource, and monitors review process and provides review outcomes report at designated intervals.
QUALITY IMPROVEMENT:
- Identifies opportunities for increasing specificity and accuracy of clinical documentation, and documents improvement activities into database/system.
- Identifies potential opportunities for improvement related to key quality indicators included in public reporting and value based payment programs (e.g., Patient Safety Indicators, Hospital Acquired Conditions, etc.)
- Collaborates with Health Information Management to optimize process related to specific high volume, high risk diagnoses and to assure correct provisional and final DRG assignment.
- Provides timely feedback to physicians, patient care team and other departments about documentation improvement opportunities.
EDUCATION AND TRAINING:
- Promotes best practices and ongoing education through specific internal communications, written educational materials and/or just-in-time training.
- Reviews trends and Identifies opportunities for training and education.
- Develops, updates, coordinates and/or delivers training and education programs.
PERFORMANCE MANAGEMENT AND CONTINUOUS IMPROVEMENT:
- Seeks and responds to regular performance feedback.
- Supports and assists the team when necessary.
- Contributes ideas and actions toward continuous improvement of processes and workflows.
- Recognizes and communicates potential issues to appropriate leader.
[Equivalent experience will be accepted in lieu of the required degree or diploma]
Bachelor's:
Nursing, Health Information Management, Healthcare Administration or related field
TYPICAL EXPERIENCE:
5 years of recent relevant experience.
SKILLS AND KNOWLEDGE:
Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.
Knowledge of age-specific needs and the elements of disease processes and related procedures.
Knowledge of current coding classification and reimbursement guidelines and regulations.
Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.
Ability to define issues, collect data, establish facts and draw valid conclusions.
Demonstrates a proactive approach in identifying and addressing issues and concerns.
Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.
Ability to communicate through verbal and written means, and to present information to a variety of audiences.
Ability to create and translate data into reports and presentations for appropriate audience.
Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.
Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.
Demonstrates initiative in providing feedback/input to improve workflow/processes.
Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.
Ability to maintain and work discreetly with confidential information.
Ability to use essential applications and/or databases associated with the role's duties and responsibilities.
PHYSICAL ACTIVITIES AND REQUIREMENTS:
See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements
Job Shift:
Days
Schedule:
Full Time
Shift Hours:
8
Days of the Week:
Monday - Friday
Weekend Requirements:
None
Benefits:
Yes
Unions:
No
Position Status:
Non-Exempt
Weekly Hours:
40
Employee Status:
Regular
Number of Openings:
1
Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
Pay Range is $59.82 to $89.73 / hour
The salary range for this role may vary above or below the posted range as determined by location.
This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled.
Compensation takes into account several factors including but not limited to a candidate's experience, education, skills, licensure and certifications, department equity, training and organizational needs.
Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.