Minimum Qualifications:

Certified Registered Health Information Administrator (RHIA) or Technician (RHIT) with a minimum of 3 years inpatient coding experience and documented education in anatomy/physiology, and pharmacology

OR

Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise, and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.

Licenses, Registrations, or Certifications

RN current license or RHIA/RHIT

Must acquire CCDS or CDIP certification within 3 years of hire.

Job Description:

Scope: Responsible for the overall improvement of the quality and accuracy of medical record documentation through interaction with physicians, members of the patient care team and hospital coding staff.

Function: Ensures clinical documentation accurately reflects the appropriate level of service provided, severity of illness, and risk of mortality of each patient. Successfully facilitates the accurate representation of patient status that translates into coded data.

Job Duties:

• Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Understand the general flow of health information from medical record documentation and discharge, through coding, to billing and finally to data reporting.
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG.
• Enter review information and working MS-DRG/APR-DRG’s with associated length of stay in the shared information system, and updates this information as needed to reflect any changes in patient’s status, procedures and treatments.
• Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation for clarification.
• Conduct follow-up of posted queries to ensure queries have been answered and physician responses have been appropriately documented.
• Educate and communicate clinical documentation opportunities in the appropriate hospital venues for staff and physician learning opportunity.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Assume responsibility for professional development by participating in workshops, conferences and/ or in-services.
• Keep current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.
• Maintain positive and open communication with physicians, members of the patient care team, case management and hospital coding staff.
• Adhere to internal controls and reporting structure.
• Comply with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.

Knowledge/Skills/Abilities:

Demonstrate excellent observation skills, analytical thinking and problem solving plus good verbal and written communication.

Preferred Certifications:

CCDS or CDIP

Salary Range:

Actual salary commensurate with experience.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.