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Job Summary
The RN Clinical Documentation Improvement Specialist performs on-site medical record reviews, examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate. This is accomplished by a concurrent and retrospective review of medical records. Responsible for the validation of diagnosis codes and the identification of missing diagnosis so that patient severity of illness is properly reflected in the medical record.
Accountabilities
• Facilitates appropriate clinical documentation to support diagnosis coding and ensure the level of service is recorded. Works with physicians on assigned patient care units to clarify clinical documentation in the patient’s medical record through a concurrent review process throughout the patient’s inpatient stay. Requests clarification of clinical documentation from the physician(s) on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge.
Ensures the level of service rendered to patients, and the patient’s severity of illness is accurately documented and recorded. Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record. Interacts with physicians as needed to discuss and advise on clinical documentation requirements. Provides timely and accurate responses to clinical documentation and coding questions. - 70%
• Responsible for file maintenance including entry into database for tracking and trending audit results. Communicate findings of potential or missed diagnoses and the revenue impact that were discovered during the chart audit. - 20%
• Reviews as needed any clinical documentation issues with the HIM Coding Staff to identify clinical documentation and coding opportunities; and to refine the concurrent review process based on post discharge coding reviews. Meets with the HIM Coding Staff on a quarterly basis to participate in post-discharge coding reviews and/or other coding education to ensure the most accurate DRG (Diagnosis-Related Group) has been assigned and to identify opportunities for clinical documentation improvement on future cases. Maintains clinical documentation that allows HIM Coding Staff to accurately code principal and secondary diagnoses, capture complications and commodities and assign an accurate and final DRG upon patient discharge. Reviews as needed any clinical issues with HIM Coding Staff and physicians to identify those diagnoses that impact severity of illness indicators for each patient. Follows up with required documentation that results in the accurate capture of the severity of illness and/or mortality. Collaborates with physicians to obtain documentation that most accurately reflects patient’s severity of illness. – 5%
• Remain current on risk adjustment / HCC (Hierarchical Condition Category) methodologies to ensure focus on most relevant diagnoses. Keep informed of changes to the risk adjustment / HCC process and participate as needed in special projects relevant to risk adjustment changes. – 5%
Supervisory/Management Responsibilities
• This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
• Associate’s Degree – Nursing
• 3 years – Inpatient nursing experience in Critical Car
Required Certifications/Registrations/Licenses
• SC RN License
In Lieu Of The Minimum Requirements Listed Above
• N/A
Other Required Sills and Experience
• Experience with 3M 360 computer assisted coding application – Preferred
• CCDS (Certified Clinical Documentation Specialist) from ACDIS (Assoc of Clinical Documentation Improvement Specialists) or CDIP (Certified Documentation Improvement Practitioner) from the AHIMA (American Health Information Management Association) – Preferred
• Experience with ICD 10-CM, familiarity with DRG and HCPCS coding systems – Preferred
• 1 year progressively responsible CDI experience – Preferred
Work Shift
Day (United States of America)
Location
5 Medical Park Rd Richland
Facility
7001 Corporate
Department
70017540 Clinical Documentation Integrity
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