POSITION SUMMARY: Responsible for support to the hospital#s clinical documentation review program, that covers the following functions: medical record review, communication and direction of clinical staff to comply with supportive documentation standards; monitoring regulatory/accreditation compliance; staff education and training.Responsible for educating providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code sets.
Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team. # EDUCATION/CERTIFICATION: Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDIPractioner preferred. Current Connecticut RN license, Medical Graduate or PA, minimum 3-5 years clinical experience or related health care field or equivalent experience.
Minimum of 1 years working in healthcare Clinical Documentation Improvement.
Knowledge of care delivery processes and related medical record documentation tools. Ability to work independently in a time oriented environment.
Excellent demonstrated oral, written and communication skills. Working knowledge of medical necessity criteria. Ability to use computer software for managing work files, data collection and data entry.
Physical requirements: Standing, walking, sitting, bending and reaching. Most work performed on the patient care units.
Must have basic computer skills. Perform automated functions that fall within job responsibility.
Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job.# They are intended to be accurate reflections of the principal duties and responsibilities of this position.# These responsibilities and competencies listed below may change from time to time.# Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position Facilitate modifications to clinical documentation supporting appropriate reimbursement is received for the level of service rendered to all patient.
Ensure that clinical documentation reflects the level of service rendered to patients in complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services 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. Aid in identification and proper classification of complication codes (patient safety indicators/hospital-acquired conditions) and medical necessity by acting as an intermediary between coding staff and medical staff Appropriately communicate with physicians regarding documentation opportunities and clinical documentation requirements. Identify patterns, trends, variances, and opportunities to improve documentation review processes.
Ensure the accuracy and completeness of clinical information used for core measures by prompting physicians. Educate all clinicians on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient#s chart.
Comply with HIPAA and code of conduct policies. Review clinical issues with coding staff to assign a working DRG. Serve as a member of the DRG Work Group.
Advise and consult with the electronic health record development team to ensure the enabling of CDI efforts Participate on departmental and hospital committees and assigned task forces, including denials management. Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization. *cb
Eastern Connecticut Health Network