Clinical Documentation Specialist

3 weeks ago

Cincinnati, Ohio, United States Ensemble Health Partners Full time

Unlock Your Potential at Ensemble Health Partners

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. Our comprehensive suite of point solutions empowers clients across the country to optimize their revenue cycle performance.

The Opportunity:

The Clinical Documentation Specialist plays a vital role in facilitating and obtaining accurate physician documentation for patient clinical conditions or procedures. This position requires extensive medical record review and interaction with physicians, nursing staff, and other patient care givers to ensure documentation is complete and accurate.

Key Responsibilities:

  • Conduct initial patient medical record reviews within 24-48 hours of admission, and subsequent reviews every 24-48 hours, entering review findings in the CDE software system.
  • Assign Principal diagnosis, CC/MCC, evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house, assigning working ICD-10-CM and PCS codes and DRG using the encoder in CDE software.
  • Clarify missing, unclear, unsupported, or conflicting health record documentation by requesting and obtaining additional documentation from physicians, utilizing face-to-face interactions and written clarifications.
  • Educate key healthcare providers on clinical documentation improvement, documentation guidelines, and the need for accurate and complete documentation in the health record.
  • Partner with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment, reviewing DRG denial letters and writing denial appeal letters.
  • Collaborate with care coordination, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.
  • Maintain and uphold all clinical documentation regulatory guidelines.
  • Formulate and submit timely, well-prepared appeals for reconsideration by third-party administrators (payors), including supporting documented clinical evidence, Coding/CDE Guidelines, and other regulatory standards/guidelines as appropriate.

What We Offer:

  • A comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
  • A culture rooted in collaboration, growth, and innovation, where associates can do their best work and be their best selves.
  • Investment in your professional development, including professional certification relevant to your field and tuition reimbursement.
  • Quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

Ensemble Health Partners is an equal employment opportunity employer, committed to diversity and inclusion. We prohibit harassment of applicants or employees based on protected categories and provide reasonable accommodations to qualified individuals with disabilities.

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