Clinical Documentation Specialist
23 hours ago
We are seeking a highly skilled Clinical Documentation Specialist to join our team at Hackensack Meridian Health. As a key member of our clinical documentation improvement team, you will play a critical role in ensuring the accuracy and quality of clinical documentation that supports code assignment for compliance with billing regulations.
Key Responsibilities- Perform data quality reviews on Inpatient Clinical Documentation Improvement (CDMP) records to ensure compliance with billing regulations and coding guidelines.
- Validate ICD-10-CM codes, DRG group appropriateness, and ensure compliance with all DRG mandates and reporting requirements.
- Monitor Medicare and other DRG payment bulletins and manuals, and review the current Office of Inspector General work plans for DRG risks.
- Identify patterns, trends, and variations in the facility's frequently assigned DRG groups and provide recommendations for improvement.
- Evaluate the quality of clinical documentation in conjunction with the Clinical Documentation Department nursing staff to spot incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payments.
- Provide training to facility healthcare professionals, including physicians, on use of coding guidelines and practices, proper documentation techniques, medical technology, and disease processes as it relates to DRG and other clinical data quality management factors.
- Report all relevant information to the facility Compliance Committee on a quarterly basis.
- Provide feedback to CDMP Manager regarding CDMP nurses for performance evaluation purposes.
- Conduct regularly scheduled in-service education for CDMP based upon the data quality reviews of CDMP DRG assignment and failures in the coding query process.
- Inform CDMP staff of changes to ICD10 coding and DRG grouper logic.
- Provide feedback to coders regarding their coding and grouping errors.
- Responsible for re-coding/reviewing consecutive accounts for Medicare 24 hour readmit accounts, Medicaid 7 day readmit accounts, and Medicare 3 day rule accounts as indicated by Case Management/Admissions.
- Daily monitoring of the PFS communication WQs and address accounts referred to coding for review.
- Makes coding changes and performs account activity to send to Finance for rebilling.
- Performs coding quality reviews as needed on accounts referred to coding by auditing companies, Finance/PFS, and/or ancillary/external departments.
- Reviews CDI quality liaison recommendations as it relates to mortality, PSI/HAC, POA and risk adjustment codes and makes changes as needed in compliance with coding guidelines.
- Bachelor's Degree or equivalent years of experience.
- Formal Health Information Management (HIM) education.
- Minimum of 5 years progressive coding review in ICD-10-CM and DRG methodologies.
- Knowledge of POA/HAC, PSI and core measures.
- Knowledge in data collection.
- Good oral and written communication skills.
- Excellent written and verbal communication skills.
- Proficient computer skills including but not limited to Microsoft Office and Google Suite platforms.
- Knowledge of the DRG structure and regulatory requirements.
- Experience in claims processing and data management responsibilities.
- Knowledge in Patient Safety/Quality Management.
- Auditing experience.
- Certified Coding Specialist.
Hackensack Meridian Health is a leading healthcare organization in the region, committed to delivering high-quality, patient-centered care to our communities. We are dedicated to advancing our mission to transform healthcare and serve as a leader of positive change.
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