Specialist - Clinical Documentation Integrity: CORP - Health Information Mgmt
Memorial Healthcare System

Job Info

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Summary:
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation to ensure that the patient's acuity of care and severity of illness are accurately reflected in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to ensure that clinical documentation is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Reviews electronic medical records to construct compliant provider documentation clarifications.

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Detailed responsibilities:
• Reviews inpatient electronic medical records and constructs compliant provider clarifications to ensure that patient documentation reflects appropriate severity of illness and risk of mortality.
• Assigns and updates appropriate working DRG, diagnoses and procedures during initial and continued stay record reviews. Collaborates with Quality Management and Population Health specialists to advise of Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and Bundled Payments for Care Improvement (BPCI) admit diagnoses/Diagnosis Related Groups (DRGs).
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient s chart.
• Provides ongoing, one-on-one, or group education related to documentation integrity and compliance to physicians, extenders, nursing, clinical dieticians, wound care specialists, physical therapists and other allied health professionals. Collaborates with Auditor, Clinical Documentation Integrity (CDI) Compliance for education topics for staff training.
• Works with Medical Director, HIM to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation.
• Collaborates with coding staff to review patient's clinical presentation/disease process, coder posed provider clarifications, and seeks guidance related to coding guidelines and assigned DRG.
• Generates CDI reports to monitor expected provider clarification and response rates, impact on case mix index (CMI) and reimbursement as appropriate.
• Maintains strict adherence to patient confidentiality according to MHS standards and regulatory requirements.
• Performs all duties as requested.

Competencies and skills:
Essential:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.

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Education:
Essential:
• Accredited Program

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Credentials:
Essential:
• Registered Nurse License

Education equivalent experience:
Essential:
• in Nursing or graduate of an accredited school of HIM.

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Other information:
Complexity of Work: Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Proficient in basic computer skills including Microsoft office applications, computerized encoder software and electronic medical record system. Ability to work well with physicians and other allied health staff.

Required Work Experience: RN with two (2) years of clinical nursing experience or RHIA/RHIT with two (2) years inpatient coding experience or CCS with two (2) years inpatient coding experience.

Registered RN or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS).

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Working conditions:
Essential:
• Bending and Stooping ; ; ; 60.00%
• Keyboard Entry ; ; ; 60.00%
• Kneeling ; ; ; 40.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient ; ; ; 40.00%
• Pushing or Pulling 0 - 25 lbs Non-Patient ; ; ; 60.00%
• Pushing or Pulling 26 - 75 lbs Non-Patient ; ; ; 60.00%
• Reaching ; ; ; 40.00%
• Repetitive Movement Foot/Leg ; ; ; 40.00%
• Repetitive Movement Hand/Arm ; ; ; 60.00%
• Sitting ; ; ; 60.00%
• Squatting ; ; ; 40.00%
• Standing ; ; ; 60.00%
• Walking ; ; ; 60.00%
• Audible Speech ; ; ; 60.00%
• Hearing Acuity ; ; ; 60.00%
• Depth Perception ; ; ; 60.00%
• Distinguish Color ; ; ; 60.00%
• Seeing - Far ; ; ; 60.00%
• Seeing - Near ; ; ; 60.00%
• Communicable Diseases and/or Pathogens ; ; ; 40.00%
• Dust ; ; ; 40.00%
• Computer Monitor ; ; ; 60.00%
• Domestic Animals ; ; ; 40.00%
• Wet or Slippery Surfaces ; ; ; 40.00%

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Organizational Profile:
Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities. We invite you to join one of the nation's leading healthcare systems, recognized for use of advanced technology and clinical informatics.

Memorial Support Services provides a variety of business services to support our facilities. The main offices are located in Miramar with satellite offices located throughout our system.

Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.