Clinical Documentation

Found in: Appcast Linkedin GBL C2 - 3 weeks ago

Morristown, United States Atlantic Health System Full time

The Clinical Documentation Specialist will facilitate modifications to clinical documentation, through concurrent interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity.


The specialist shall concurrently review and evaluate selected patient’s medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, coding professionals on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.

Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.


90%- Case Audits Initial. Concurrent and Final

10%- Participate in Subcommittees for various Disciplines

Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and to assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.

Completes the initial review within 24-48 hours of admission.

Completes concurrent reviews to ensure working DRG, SOI and ROM and all comorbid conditions are documented by the providers to the greatest specificity

Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.

Educates internal staff on clinical documentation and coding guidelines. Develops and conducts ongoing education for new clinical documentation specialists, coders, physicians, residents.

Develops and supports strong professional relationships with CDS, Coding staff, Physician advisors and medical providers across the system.

Utilizes a compliant query process per guidelines and policy when conducting all queries.

Follows each query through to closure including complete documentation of ongoing follow up activities and communication.

Provides ongoing CDS team learning opportunities through sharing of professional knowledge.

Maintains integrity and compliance in all chart reviews and CDI documentation and queries.

Supports and implements quality measures as identified by AHS system





Education:

Licensed Registered Nurse credentialed from the NJ Board of Nursing

Licenses:

NJ RN License required

Required Experience:

Required and minimum of three years of experience in the acute-care setting in: surgical, intensive care, emergency medicine preferred. An advanced understanding of anatomy, physiology, pathophysiology and pharmacology is required.

Preferred prior CDI experience required.

Certifications:

One of the following preferred: CCDS, CDIP, CCS


Other:


Knowledge of word processing software, spreadsheet software and reporting software. Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred 3M EPIC Iodine

Demonstrates excellent interpersonal relationship skills

Capable of acting independently

Knowledge of CMS regulations along with DRG groupings

Coding skills with experience in ICD-10-CM/PCS and working knowledge of the AHA Coding Clinic (some training provided)

Requires ability to work with and maintain confidential information.

Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts.

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