Job description

Location: Remote

Duration: 13 Weeks-3 Months

REQUIRED EXPERIENCE: Min 3 yrs exp in HIM- (Health information management) OR Min 3 yrs acute hospital inpatient coding exp (Highly Pref'd)
REQUIRED EDUCATION/CERTIFICATION: MD or Current TX (or compact) RN license (ADN req'd, BSN highly pref'd) at time of submission CDIP or CCDS CCS (Preferred)

POSITION SUMMARY:

• The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation.
• The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records.
• The CDS will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement (reflecting proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.

COMPETENCIES FOR ASSOCIATES:

• Action oriented - Taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm.
• Customer focus- Building strong customer relationships and delivering customer-centric solutions.
• Communicates effectively- Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
• Decision quality- Making good and timely decisions that keep the organization moving forward.
• Collaborates- Building partnerships and working collaboratively with others to meet shared objectives.
• Nimble learning- Actively learning through experimentation when tackling new problems, using both successes and failures as learning fodder.
• Demonstrates self-awareness- Using a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses.

MAJOR RESPONSIBILITIES:

• Performs concurrent and retrospective reviews of the medical record utilizing evidence-based knowledge, protocols and criteria.
• Works closely with the medical staff and other healthcare team member to help identify potential gaps in physician documentation and ensuring appropriate reimbursement is received for the level of service rendered to all patients.
• Utilizes research, analytic data and observations to provide recommendations to improve the overall quality and completeness of clinical documentation.
• Establishes cooperative and multidisciplinary relationships with physicians, coding staff and other health team members.
• Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs and successful problem resolution.
• Demonstrates familiarity with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS).
• Completes initial reviews of patient records to evaluate documentation to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness.
• Completes follow-up reviews.
• Reviews a minimum of standard charts per day as directed.
• Analyzes clinical information. Formulates appropriate clinical documentation clarifications to improve documentation. Queries and educates physicians and key healthcare providers regarding clinical documentation improvement.
• In conjunction with CDI leadership, tracks response to clinical documentation and trends in CDI metrics.
• Maintains and enhances current medical, coding and CDI knowledge by participating in continuing education offerings.
• Consistently meets established productivity targets for record review.
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities.
• Performs all duties in a manner that protects the confidentiality of the patient and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.
• Performs other duties as assigned.

POSITION SPECIFIC COMPETENCIES:

• Strong clinical knowledge and understanding of pathology / physiology of disease processes
• Excellent interpersonal skills to build excellent relationships with physicians, nurse, staff and to be able to educate them
• Must work independently and manage goal productivity; must be efficient and accurate in performance
• Working knowledge of MS-DRG and APR-DRG highly preferred
• Must be familiar with the other functions in Medical Records and how they relate to the Coding function
• Must be able to read and decipher handwriting that is difficult to read.

Job Type: Contract

Salary: $66.00 - $70.00 per hour

Education:

• Bachelor's (Required)

Experience:

• Health information management: 3 years (Required)
• inpatient coding: 3 years (Required)

License/Certification:

• CDIP (Required)
• CCDS (Required)
• CCS (Required)

Work Location: Remote

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