Clin Document Improvement Spec (40 hrs)(Temple Health)

Temple University Health System • Philadelphia, PA

1d • Onsite

About The Position

Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medicalk complexity. Additionally, the CDI specialist will be the primary educator for the implementation of the International Classification of Disease Classification System, 10th revision. The CDI specialist shall be responsible for clarifying documentation regarding quality of care issues. Responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital based coding system utilizing ICD-10. Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics. Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation.

Requirements

• Bachelor's Degree in a related field or an Associate's degree in a healthcare related field with 5 years of related experience
• 2 years experience in Patient care or Coding (inpatient medical setting)

Nice To Haves

• 5 years experience in inpatient acute care
• Certified Coding Specialist
• PA Practical Nurse License
• PA Registered Nurse License
• Multi State Compact RN License

Responsibilities

• Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity.
• Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medical complexity.
• Will be the primary educator for the implementation of the International Classification of Disease Classification System, 10th revision.
• Responsible for clarifying documentation regarding quality of care issues.
• Responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital based coding system utilizing ICD-10.
• Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics.
• Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation.

Benefits

• Your Tomorrow is Here! Temple Health is a dynamic network of outstanding hospitals, specialty centers, and physician practices that is advancing the fight against disease, pushing the boundaries of medical science, and educating future healthcare professionals.
• Temple Health consists of Temple University Hospital (TUH), Fox Chase Cancer Center, TUH-Jeanes Campus, TUH-Episcopal Campus, TUH-Northeastern Campus, Temple Physicians, Inc., and Temple Transport Team.
• Temple Health is proudly affiliated with the Lewis Katz School of Medicine at Temple University.
• To support this mission, Temple Health is continuously recruiting top talent to join its diverse, 10,000 strong workforce that fosters a healthy, safe and productive environment for its patients, visitors, students and colleagues alike.
• At Temple Health, your tomorrow is here!
• Temple Physicians Inc. brings the best together.
• Our people enjoy something truly unique - settings with the resources of a world-class health system and the personal connections of a neighborhood doctor's office.
• With convenient locations, leading edge care, and staff who feel more like family, careers with Temple Physicians are second to none.
• Do you enjoy getting to know patients in a professional setting?
• Appreciate the possibilities and support offered by a large health system?
• Then join Temple Physicians, Inc.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree