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Performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.
Qualifications
Must have prior experience as a Clinical Documentation Specialist
1 year of experience as a Clinical Documentation Specialist
Additional two years in an acute care setting or relevant experience
Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)
CCDS certification preferred
Proficiency with MS Office Tool - especially Excel
Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews
Requirements
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, ROM, and SOI
Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary
Queries physicians regarding missing, unclear, or conflicting health record documentation
Identifies issues with reporting of diagnostic testing proactively
Enhances expertise in query development, presentation, and standards
Educates physicians and key healthcare providers regarding clinical documentation improvement
Attends department meetings to review documentation related issues
Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics
Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy
Troubleshoots documentation or communication problems proactively
Reviews and clarifies clinical issues in the health record with coding professionals
Assists in the mortality review and risk adjustment process utilizing third-party models
Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record
Imparts knowledge to providers and other members of the healthcare team
Maintains a level of expertise by attending continuing education programs
Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice
Works in a constant state of alertness and safe manner
Performs other duties as assigned
Education
Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)
Experience
Two years in an acute care setting or relevant experience
Physical Requirements
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more)
Frequent use of hearing and speech to share information through oral communication
Frequent keyboard use/data entry
Occasional bending, stooping, kneeling, squatting, twisting and gripping
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs
Rare climbing
Required Professional License and/or Certifications
State of Work Location: Illinois
Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
Or Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR)
Or Physician - Regional MSO Credentialing
Or Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Or Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Or APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
Or Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
Or Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR)
State of Work Location: Missouri
Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
Or Physician Assistant - Missouri Division of Professional Registration
Or Physician - Regional MSO Credentialing
Or Registered Nurse (RN) Issued by Compact State
Or Registered Nurse (RN) - Missouri Division of Professional Registration
Or Nurse Practitioner - Missouri Division of Professional Registration
State of Work Location: Oklahoma
Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
Or Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board
Or Physician Assistant - Oklahoma Medical Board
Or Physician - Regional MSO Credentialing
Or Registered Nurse (RN) Issued by Compact State
Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
Or Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN)
Or Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP)
State of Work Location: Wisconsin
Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
Or Physician Assistant - Wisconsin Department of Safety and Professional Services
Or Physician - Regional MSO Credentialing
Or Registered Nurse (RN) Issued by Compact State
Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
Or Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services
Benefits
Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE)
Flexible Payment Options: instant access to earned, unpaid base pay through DailyPay (fees may apply)
Upfront Tuition Coverage: upfront tuition coverage through FlexPath Funded for eligible team members
