Specialist Clinical Documentation I

Description

This position may qualify for a sign-on bonus.

SUMMARY:

Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff. Ensures the accuracy and completeness of clinical information used for measuring andreporting physician and hospital outcomes. Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Completes established competencies for the position within designated introductory period. Other related duties as assigned.

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Responsibilities:

 

• Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record
• query process.
• Serves as a resource for physicians to help link ICD-10-CM/PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment
• Works in collaborative fashion with the Coders and Case Managers concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment
• Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals
• Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals
• Performs monthly closed chart reviews and serves on the Chart Documentation Committee
• Identifies, assist and participates in intradepartmental and interdepartmental special projects involving accuracy of physician documentation and reporting outcomes
• Utilizes resources efficiently and effectively
• Maintains safe environment
• Participates in Performance Improvement activities

Qualifications

MINIMUM EDUCATION: Graduate of an accredited school of Nursing, AHIMA accredited school, United States or international school of medicine.
PREFERRED EDUCATION: Bachelor’s Degree in Health Information Management and/or Nursing or related healthcare Degree.
MINIMUM EXPERIENCE: 0-2 years of CDS experience and 2 years of recent acute care experience in a clinical or inpatient coding setting.
PREFERRED EXPERIENCE: 4 or more years of experience in acute care setting
REQUIRED CERTIFICATIONS/LICENSURE: RHIA, RHIT, CCS, CIC, Certified Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), RN, LVN, LPN, MD, DO, PA, NP.
PREFERRED CERTIFICATIONS/LICENSURE: NA
REQUIRED COURSES/ COMPLETIONS (e.g., CPR): NA
 

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Baptist Health System has more than 120 years history of caring for our community and making a positive difference. Our system of care includes six full-service hospitals, a specialized childrens hospital with a dedicated pediatric emergency unit, a comprehensive cancer care network, fitness and rehabilitation centers, a physician network, imaging centers, ambulatory services and the Baptist School of Health Professions. Wherever you go in the Baptist Health System, youll find that we have the same goal to help people achieve health for life through compassionate service inspired by faith. Join our team!

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