CLINICAL DOCUMENT SPECIALIST

Overview

Facilitates and obtains appropriate and complete medical record documentation to reflect patient acuity level and care provided. Ensures that clinical documentation is accurately and compliantly captured at the point of service.

Responsibilities

PRINCIPAL DUTIES AND RESPONSIBILITIES(*Essential Functions)

Responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment for billing integrity. Reviews all provider documentation as necessary to ensure complete and accurate documentation.  Collaborates with HIM Coders to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and reimbursement is received fro the level of services rendered to patients with DRG-based payers.

Participates in education of members of the patient care team on documentation guidelines as guided by department leadership.

Collect and analyze data to provide reports and make recommendations.

Completes admission reviews of patient records within 24-48 hours of admission for specified patient population to evaluate documentation and generate the working DRG.

Conducts concurrent follow-up reviews of records as necessary, not to exceed 4 days from prior review.  Update notes and revise working DRG based on new documentation.

Electronically query physicians/other providers regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation within the medical record when needed.

Document all reviews in the CDI application to facilitate tracking, data collection, and communication with coders and department leaders.

Take all necessary action to resolve physician queries prior to patient discharge.

Contribute to and participate in physician, nursing, and other ancillary staff education documentation requirements.

Utilize EHR Clinical Documentation Improvement process flow tools to collect data to support reporting of required indicators - Number of reviews per day/patient - Query generation - Query completion to include outcome - Current and expected DRG with weight change - APR-DRG SOI score improvement.

Make recommendations for change processes required to capture needed documentation, such as note template and query content redesign.

Qualifications

JOB SPECIFICATIONS(Minimum Requirements)KNOWLEDGE, SKILLS, AND ABILITIES

• Registered Health Information Technologist/Registered Health Information Administrator
• Excellent communication skills
• Ability to work independently and in a team environment.
• Self-starter, professional courtesy, positive attitude.
• Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality, and integrity of employee, patient and family, organizational, or other medical information.  Understands and supports the commitment of Methodist Hospitals in adhering to federal, state, and local laws, rules, and regulations governing ethical business practices for healthcare providers.

EDUCATION

• Requirements for this position are: a. An Associate's Degree from a recognized college or university in Nursing and a current Registered Nurse licensure in the State of Indiana, OR b. A Bachelor's Degree from a recognized college or university in health records management or a closely related field and RHIA.
• Associates Nursing Required
• Bachelors Health Information Required
• Minimum 2 years inpatient hospital coding experience
• 2 years Healthcare/Medical - Health Information Systems/Technology/MIS Required
• Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management
• RHIA - Registered Health Info Administrator
• RHIT - Registered Health Info Technician
• Licensed Registered Nurse

STANDARDS OF BEHAVIORMeets the Standards of Behavior as outlined in Personnel Policy and Procedure #1, Employee Relations Code.CONFIDENTIALITY/HIPAA/CORPORATE COMPLIANCEDemonstrates knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family, organizational and other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state and local laws, rules and regulations governing ethical business practices for healthcare providers.DISCLAIMER - The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. The statements are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required.