Clinical Documentation Specialist-4
3 weeks ago
Provides extensive record reviews and interaction with physicians, HIM professionals, and nursing staff.
Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
ESSENTIAL FUNCTIONS:
Communicates with physicians, coders, and other health team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatientsEvaluate documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedures for accurate DRG assignment, risk of mortality, and severity of illnessIdentifies opportunities for documentation improvement to ensure accuracy and completeness of documentation used for measuring and reporting physician and hospital outcomesQueries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when neededProvides education to all physicians and other clinicians related to compliant documentation responsibilities and coding and reimbursement issues.Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of documentation to determine a working and final DRG.Facilitates changing of processes required to accurately capture needed documentation, such as forms redesign.Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.Abides by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI).MINIMUM KNOWLEDGE AND SKILLS REQUIRED:
Knowledge of ICD-9, ICD10 and their application, with an understanding of medical records.Ability to read, discuss, and interpret information and ideas essential to patient care.Basic computer skills and familiarity with Windows based software programs.Demonstrated ability to communicate effectivelyPREFERRED KNOWLEDGE AND SKILLS:
Medicare Part A, Part B, DRG’s.PREFERRED BEHAVIORAL SKILLS:
Integrity:A personal presence which is characterized by a sense of honesty and the willingness to do the right thing.The ability to role model, inspire and motivate others to promote the philosophy, mission, vision, goals and values of Hutchinson Regional Healthcare SystemCompassion:A personal presence which is characterized by a sense of caring that is reflected in a high level of empathy and customer service with all that we come in contact.Ability to manage conflict, consider other points of view, and offer alternative solutions without jeopardizing overall project direction and the ability to manage customer expectations.Accountability:Demonstrated track record of ownership of situations, projects and issues.Able to work autonomously and have a high degree of flexibility to adapt to changing projects, priorities and work volumes.Respect:Demonstrated ability to collaborate with a diverse population.Treat all internal and external customers with a positive, proactive service orientation.Excellence:Strong communication skills and the ability to service our customers with the highest of standardsMINIMUM EDUCATION AND EXPERIENCE REQUIRED:
Graduate of a Credited Registered Nursing Program Or Credentialed CCS CoderMinimum of 2 years’ experience in acute hospital nursing and/or 4 yrs advanced Inpatient CodingDemonstrated knowledge of DRG, MS- DRG, Severity of illness and Risk of MortalityPREFERRED EDUCATION AND EXPERIENCE:
BSNMinimum of 2 years’ experience in clinical documentation improvement preferred.REQUIRED LICENSE/REGISTRATION/CERTIFICATION:
Current licensure as an RN in the State of Kansas and/or Credentialed Coding Specialist (CCS)PREFERRED LICENSE/REGISTRATION/CERTIFICATION:
Certified Documentation Improvement Professional (CDIP)Healthcare Provider BLSWe offer competitive pay, a generous benefit package and a reason to be proud of what you do, every day.
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