Clinical Documentation Specialist- Full-Time, Days

Northwestern Medicine Huntley , IL 60142

Posted 2 weeks ago

This position will provide active concurrent and retrospective review of documentation and assign ICD-10-CM codes as appropriate to the IRF-PAI as well as for the UB-04. As documentation is reviewed, this position will also provide feedback and educate clinical care providers to improve the documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care.

Analyze health record to identify etiologic diagnosis and all co-morbidities and complications. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Ensures all required documentation to meet IRF medical necessity is complete and timely.

Queries the medical staff and other clinical caregivers as necessary. Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement issues or missing documentation. Communicates documentation issues clearly and succinctly to clinical care providers and reports issues/ trends to appropriate manager.

Provides ongoing education to physicians and other clinical care providers related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes. Monitor changes in law, regulations, rules, and code assignment that impact documentation and reimbursement. Coordinates and maintains all elements of the Clinical Documentation Improvement Program to meet the goals and objectives of the organization and its stakeholders.

Meet CDI program objectives, goals, quality, productivity guidelines, standards and Dashboard metrics. Ensures timely, accurate, and complete clinical documentation used for measuring and reporting physician and hospital outcomes. Identifies trends and opportunities for improvement in clinical documentation in relation to federal, state or private third-party payers.

Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies. Work effectively with CDI team members to accomplish departmental goals. Demonstrates continued advancement in professional growth. AA/EOE.

Required: RN. Successfully manages multiple priorities required.

Computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required. Ensure effective communications with key stakeholders. Preferred: Preferred RHIA, RHIT, and/or CCS.

CDIP not required but a plus. Preferred experience in an IRF (Inpatient Rehab Facility).



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Clinical Documentation Specialist- Full-Time, Days

Northwestern Medicine