Clinical Documentation Quality Liaison
4 weeks ago
Our team members are the heart of what makes us better.
At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
Under the direct supervision of the Regional Manager, the Clinical Documentation Quality Liaison is responsible for promoting high-quality clinical documentation by collaborating with the CDI, HIM, Quality Departments as well as with the Medical and Surgical Service Lines across the central and south regions of Hackensack Meridian Health (HMH). Promotes improvement initiatives directed at system-wide quality indicators (i.e. Mortality, Patient Safety Indicators [PSI], Hospital Acquired Conditions, Severe Maternal Morbidity, etc.) and clinical evidence to support DRG, principal diagnosis, and secondary diagnoses assignments. Other duties this position may be asked to undertake include, but are not limited to, performing second level CDMP chart reviews for accuracy and compliance when there is a discrepancy in the Clinical Documentation Specialist and Coder DRG and coaching of the CDMP Team on PSI, review and screen inpatient admissions and observations as specified by the facility's Utilization Management/Review Committee for documentation completeness and compliance with patient status, and communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS) assigned to the unit.
Responsibilities:
A day in the life of a Clinical Documentation Quality Liaison at Hackensack Meridian Health includes:
Review within 24 hours all cases populated in the Pre-coding Mortality Work Queue/Report to ensure the documentation reflects the appropriate severity of illness (SOI) and risk of mortality (ROM).
Seek provider's clarification for any unclear, missing, conflicting, documentation.
Contact providers by any means set by CDMP policies with regards to the queries posted.
Establish and update any process flow regarding the CDMP management and communication of Mortality and PSI cases reviews.
Educate physicians on correct documentation, Mortality, PSI, and utilization of template; Create templates for different service lines.
Participate in service lines quality of education meetings, and conferences.
Review and conduct analysis of data obtained in the daily reports.
Communicate analysis to CDMP management along with new proposals to improve data.
Educate current and new CDMP Team members on quality reviews, identification of quality indicators and potential exclusions. Serve as a resource to the CDMP Department for PSI and provide review of cases and coach Team on PSI identification and exclusions.
Retro query mortality cases to increase severity of illness and risk of mortality.
Review concurrent and post coding pre-billing medical records every 24-48 hours as appropriate for completeness and accuracy to ensure the level of services and acuity of care are accurately reflected by using clinical documentation guidelines and following the established CDMP process for follow-up reviews and physician communication.
Assist in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.
Update DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses, and changes in DRG and/or APR assignment.
As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to the Regional Manager.
Utilize coding staff knowledge of Coding Clinics that impact CDMP® and in return provides clinical expertise and references to the coding staff.
Stay current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance.
Familiar with the Vizient calculator and the risk models to improve quality data.
Other duties and/or projects as assigned.
Adheres to HMH Organizational competencies and standards of behavior.
Qualifications:
Education, Knowledge, Skills and Abilities Required:
Bachelor's Degree in Nursing - BSN, RN, or equivalent relevant experience.
Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care or Emergency Room Care.
Minimum of 2 or more years of experience in Patient Safety/Quality Management.
Ability to interact well with physicians and other members of allied health care teams, including HIM coders.
Computer literate with working knowledge of Google and/or Microsoft based software programs/applications.
Excellent written and verbal communication skills.
Excellent organizational, analytical, writing and interpersonal skills.
Critical thinking, problem solving and deductive reasoning skills.
Thorough knowledge of Medicare Part A; Familiar with Medicare Part B.
Knowledge of the regulatory environment.
Excellent knowledge of POA/HAC, PSI and core measures.
Knowledge of Observation and Inpatient medical necessity criteria.
Licenses and Certifications Required:
NJ State Professional Registered Nurse License.
Certified Clinical Documentation Specialist.
Licenses and Certifications Preferred:
Certified Coding Specialist.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today
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