- Job Objective: A brief overview of the position.
- Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation. In doing so, provides on-going physician/provider education and consultation to improve the accuracy, completeness, specificity and compliance of the in-patient acute care Medical Record. Educates physicians/providers, RNs and other healthcare disciplines in understanding the importance of accurate documentation that reflects EMC's patient population as it is related to severity of illness and risk of mortality.
- Reports to
- DIRECTOR, CASE MANAGEMENT
- Supervises
- None
- Ages of Patients
- Pediatric
- Adolescent
- Adult
- Geriatric
- Blood Borne Pathogens
- Minimal/ No Potential
- Qualifications
- Education
- Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012
- Licensure/Certification
- Required: Active California RN license
- Preferred: CCS, RHIT, ICD-10 AHIMA training certification or equivalent
- Experience
- Required: A minimum of 5 years recent clinical nursing experience in an acute care setting.
- Preferred: Knowledge of MS-DRG methodology and inpatient coding rules and regulations
- Education
- Essential Responsibilities
- Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
- Performs concurrent review of medical records and identifies areas of documentation requiring clarification of comorbidities, presence of complications and the presence of an opportunity to improve documentation from the physician to accurately assign the best DRG.
- Reviews 25-35 records in assigned areas within 24 hours or first working day after admission and with evidence of ongoing record review at least every 48 hours when necessary.
- Compiles data in Midas and maintains monthly and Quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance. Tracks and reports financial and statistical data in designated system. Prepares monthly and quarterly reports for Director of Case Management
- Communicates with and works collaboratively with coding personnel to determine outcomes regarding severity/complexity and to assure all opportunities have been pursued before patients' discharge from acute care setting.
- Educates physicians and staff on Query tool as it relates to quality of documentation in the medical record.
- Reviews all defined medical records to identify laboratory, radiology, cardiac & pulmonary information and procedures pertinent to the patient's care that is not clearly documented in the medical record.
- Analyzes deficiencies and educates physicians in need for appropriate documentation to capture the complexity of care and the severity of illness.
- Implements tracking systems to measure the effectiveness of education.
- Develops and tracks, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation.
- Interfaces with physician champion regarding educational opportunities for specific documentation with physicians identified as needed additional education.
- Develops and updates pertinent policies and procedures and processes in collaboration with the Director of Case Management.
- Obtains daily census and tracks defined admissions and discharges.
- Maintains compliance to HIPAA and all other regulations related to patient confidentiality.
- Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Improvement process and outcomes.
- Communicate with team members and participate in appropriate committees to report outcome information.
- Collaborate with the Utilization Management Specialist when continued stay or level of care issues are identified.
- Assist the HIM department in facilitation of the physician query process after patient discharge.
- Performs special projects and other duties as directed.
-
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