- Reviewsinpatient medical records for identified payer populations aswithin one business day of admission and throughout hospitalizationto identify opportunities for physician documentation.
- Analyzes clinical status of patient, currenttreatment plan, and past medical history and identifies potentialgaps in MD documentation and leaves physician query to obtaincomplete, accurate clinical documentation.
- Works closely with HIM coding staff to assuredocumentation of discharge diagnosis and any co-existingco-morbidities is a complete reflection of the patient's clinicalstatus and care
- Maintain a DRG worksheet toassist coders on identifying all documented POA/HAC, diagnosis andprocedures
- Updates DRG worksheet to reflect anychanges to inpatient status/procedure/treatment and confers withthe physician to finalize diagnosis.
- Demonstrates basic knowledge about HIM codingstandards and applies to ongoing evaluation of medical recorddocumentation for accuracy of physician documentation to supportthe acuity of illness.
- Performs chart reviewon expired patients to identify severity of illness and risk ofmortality for performance improvementactivities.
- Develops and implements plans forboth formal and informal education of physician, nursing, and otherclinical staff on clinical documentation opportunities, coding andreimbursement as well as performance improvementmethodologies.
- Collaborate with case managerregarding cases with length of stay outside of the expected GMLOS,to ensure documentation identifies severity of illness andmaximizes reimbursement potential.
- Coordinatesand assures complete and accurate data collection and validationfor public reporting data initiatives for Premier, CMS andJCAHO.
- Maintains good rapport and cooperativerelationships. Approaches conflict in a constructive manner. Helpsidentify problems, offers solutions, and participates in theirresolution.
- Coordinates with qualitydepartment by: providing concurrent review for core measuresdocumentation, providing retrospective chart audits as needed, andeducating nursing and medical staff of improvement and currentstatus of quality initiates.
- Performsfollow-up to document physician response to queries. Tracks andtrends patterns of physician responses and reports monthly todirector.
- Designs and implements collaborationwith physician leadership specific tools to support medical recordphysician documentation.
- Review clinicalissues with coding staff to assign workingDRG's.
- Work collaboratively with the codingstaff to ensure that documentation of discharge diagnoses andco-morbidities are a complete reflection of the patient's clinicalstatus and care.
- Review final DRG and comparewith clinical data gathered to ensure the DRG assigned isappropriated and that all co-morbidities arecaptured.
- Communicates with Case ManagementDirector and/or Vice President of Medical Affairs regarding programbarriers/success/outcomes of CDI program.
- Assists in collection and organization of datafor analysis by appropriate medical and hospital committees.
- Consistently meets established productivitytargets for record review.
- Maintain strictconfidentiality at all time.
- Performs otherduties as assigned.
- Associate's Degree inNursing
- RN License in state of employment orcompact
Clinical Documentation Specialist, Clinical DocumentationIntegrity - Longview, United States - Christus Health
Description
Summary:
The Clinical Documentation Registered Nurse collaboratesextensively with physicians, nursing staff, other patientcaregivers and coding staff to improve the quality and completenessof documentation of care provided and coded for coordination,abstraction and submission of accurate data required by CMS.Facilitates concurrent modifications to clinical documentation toinsure commensurate reimbursement of clinical severity and servicesrendered to patients with a DRG based payer (Medicare, Medicaid).Supports timely, accurate and complete documentation of clinicalinformation used for measuring and reporting physician and facilityoutcomes. Communicates with and educates all clinical staffconcerning accurate and effective clinical documentation.
Requirements:
Work Type:
Per Diem AsNeeded
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