Job Details

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Job Summary
Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of clinical documentation. This is accomplished by medical record review, query process, and reconciliation process. Participates in the development and delivery of clinical documentation education for providers and health care team members as needed. Serves as preceptor, education resource and second level reviewer for documentation and query justification. May be called on to validate query impact for team.

Accountabilities

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation. (50%)
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (15%)
• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification. (10%)
• Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Fulfils all other duties and responsibilities of a CDIS I (5%)

Supervisory/Management Responsibilities

This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Education

Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.

Minimum Experience

• Four (4) Adult medical/surgical/critical care/ER/PACU nursing coding or related field
• Clinical documentation improvement experience (2 years)

Required Certifications/Registrations/Licenses

• One of the following certifications: RN, RHIA, RHIT, CCS, or CIC
• CCDS/CDIP

Other Required Experience

• Computer skills, keyboarding.
• Strong communication skills with ability to interact with providers and remain tactful.
• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems.

Work Shift
Day (United States of America)

Location
Corporate

Facility
7001 Corporate

Department
70017540 Clinical Documentation Integrity

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