Clinical Documentation Specialist, 20 hours
Spaulding Hospital Cape Cod(SRN and SCC)

Job Info

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Under the direction of the Clinical Documentation Integrity (CDI) Manager, facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) regulations and guidelines and assure appropriate case mix index, estimated length of stay (where applicable) and reimbursement. Collaborates with the Interdisciplinary Care Team to be successful in this role. Utilizes clinical and ICD 10 coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nurses, other patient caregivers, and Compliance, Coding, and Outcomes staff. Educates members of the Interdisciplinary Care Team on documentation guidelines on an ongoing basis. Assists with IRF CMS 60% management, concurrent CMG or DRG assignment, ICD 10 documentation accuracy, and ongoing documentation improvement.

• Reviews inpatient medical records within 24-48 hours of admission and throughout hospitalization to:
  • evaluate documentation to assign an accurate etiologic diagnosis, principal diagnosis, comorbidities and complications care mix group (CMG IRF) and diagnosis-related group (DRG LTCH)
  • documents review details for metrics, trending, and education
• Conducts follow-up reviews of patients every 2-3 days to support and assign additional diagnoses that accurately reflect care and may impact length of stay, case mix, CMG, or DRG. Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional medical record documentation as applicable
• Educates physicians and key healthcare providers regarding clinical documentation integrity and the need for accurate and complete documentation in the medical record.
• Collaborates with compliance, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Reviews external (i.e., PEPPER) and internal data (i.e., outliers) to trend, track, and educate to improve the accuracy of patient outcomes, quality reporting program, and reimbursement.
• Assists with the preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
• Instructs staff on best practices to ensure accurate documentation in the medical record.
• Maintains and reports clinical documentation integrity results in a clear and concise manner to the medical, clinical, and management staff.
• Applies diplomacy and professionalism when interacting with physicians and clinical staff, especially when addressing missing or conflicting medical record information
• Works in partnership with an interdisciplinary team to foster collaboration, learning, and accurate and complete medical record documentation.
• Exhibits skillful, up-to-date working knowledge of coding guidelines (Federal and State, etc...), researching websites, publications, and reference materials. Collaborates with the Inpatient Coding Manager to understand and adhere to coding policies and guidelines published in the "Coding Clinic" and coding department policies and procedures.
• Collaborates with compliance, coding staff, physicians, and finance to reduce payment denials and improve medical necessity documentation.
• Acts as a consultant to providers, management, administration, and billing staff with regard to documentation, coding, and reimbursement and compliance matters.
• Investigates, evaluates and identifies opportunities for improvement and recognizes their relative significance in the overall system.
• Provide orientation for new clinical staff about documentation requirements and coding/billing issues as required.
• Assists in coordinating responses to third-party payer audits and/or requests when appropriate; determine the appropriate documentation to be submitted; and formulate responses.
• Keeps current with coding changes, proposed and otherwise, through conferences, reference material, and review of current literature.
• Tracks queries in applicable software (access database)
• Maintains confidentiality of all customer/hospital information.
• Demonstrates flexibility in changing work environment, adjusting work schedule accordingly.
• Upholds the PCC Organizational Values of Innovation, Collaboration, Accountability, Respect, and Excellence.
• Other duties as assigned

Qualifications
Education

• Graduate of an accredited School of Nursing.

Licensure

• Current licensure from the Massachusetts Board of Registration to practice professional nursing.
• Certificate in Case Management or Clinical Documentation Integrity (CDIP) preferred.

Experience

• Minimum of 5 years' experience in clinical nursing, case management, HIM inpatient coding, or an equivalent combination of these disciplines.
• Knowledge of acute regulatory/accreditation requirements preferred.
• Basic knowledge of coding/classification systems appropriate for inpatient CMG and DRG prospective payment systems.

Skills

• Computer proficiency required. Microsoft Office applications are preferred with the ability to learn new software.
• High level of service delivery. Demonstrate initiative with the ability to prioritize work, meet deadlines, and adapt to changing situations.
• Work independently, be self-directed, and contribute as a leading member of a team.
• Ability to clearly present information in writing and in presentation form.
• Maintain variable work schedule to meet department needs. (evenings, holidays, weekends, and travel).

EEO Statement
Spaulding Rehabilitation is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.

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