Job Description

General Summary

Responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. Assists treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. Assesses clinical documentation through extensive review of the medical record, interaction with providers, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Duties and Responsibilities

Essential Functions:

• Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis and to assign a working Diagnosis Related Group (DRG). Performs initial reviews, concurrent reviews, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study. • Performs initial case reviews and appropriate number of follow-up reviews based on program standards. • Completes initial and follow-up medical record reviews using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data, and other pertinent components of the clinical record. • Completes the initial review, pulling cases by prioritization. • Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
• Using clinical insight and judgment, analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately queries the provider per guidelines. • Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, hospital acquired conditions (HAC), and patient safety indicators (PSI). • Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
• Maintains integrity and compliance in all chart reviews and queries.
• Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
• Develops and supports strong professional relationships with Clinical Documentation Integrity Specialists (CDS), coding staff, compliance, quality, and medical providers across the system.
• Works collaboratively with medical, nursing, and ancillary staffs to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality and anticipated/geometric mean length of stay (GMLOS).
• Demonstrates an understanding of complications, co-morbidities, severity of illness (SOI), risk of mortality (ROM), case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
• Provides CDI education to providers one on one, during staff meetings, or during department meetings.
• Provides ongoing CDS team learning opportunities through sharing of professional knowledge.
• Functions as a subject matter expert and actively participates in meetings as a problem-solver.
• Facilitates and/or supports continuous improvement activities.
• Supports and implements quality measures as identified by department manager.
• Maintains professional competency by keeping abreast of new coding issues and guidelines.
• Uses software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation.

Common Expectations:

• Prepares and maintains appropriate documentation as required.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation
• Prepares and presents data analysis as required.
• Assists with special projects and attends meetings as needed.

Qualifications

Minimum Education:

• Diploma Program in Nursing Required or
• Associates Degree Required
• Bachelors Degree Preferred

Work Experience:

• 5 years recent hospital experience with Critical Care experience (for RN without CDI experience) Required or
• CDI experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility. Required
• Clinical Documentation Integrity experience. Preferred

Licenses:

• Licensed Registered Nurse Upon Hire Required or
• Registered Nurse Multi State License Upon Hire Required or
• Licensed Medical Physician and Surgeon Upon Hire Required or
• Licensed Doctor of Osteopathic Medicine Upon Hire Required or
• Licensed Physician Assistant Upon Hire Required or
• Certified Registered Nurse Practitioner Upon Hire Required
• Certified Clinical Documentation Specialist Upon Hire Preferred or
• Certified Document Integrity Practitioner Upon Hire Preferred

Courses and Training:

• In lieu of the above Licenses and Certifications, a Medical Degree with experience as a concurrent or retrospective specialist in an inpatient acute care facility would be considered. Upon Hire Required
• Certified Clinical Documentation Specialist Upon Hire Preferred or
• Certified Document Integrity Practitioner Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills.
• Computer skills.
• Experience with PowerPoint, Excel and Microsoft Office.
• Self-directed and motivated to function both independently and on teams.

Benefits Offered:

• Comprehensive health benefits
• Retirement savings plan
• Paid time off (PTO)
• Education assistance
• Financial education and support, including DailyPay
• Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)