Clinical Doc Improv Spec 2

Baylor Scott & White Health•Dallas, TX

About The Position

Performs patient record reviews to ensure complete, accurate, and timely documentation of all conditions supporting hospitalization and treatment. Present queries to physicians to clarify unclear or incomplete documentation. Must know ICD-10, Complications/Comorbid Conditions, and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.

Requirements

Must have a Bachelor's degree in nursing or Health Information Management or Health Informatics.
Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
Requires one of these certifications: Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), BSW code (CCDOSCP), Certified Clinical Documentation Specialist Outpatient (CCDS-O), Certified Documentation Improvement Practitioner (CDIP), or Certified Professional Coder (CPC).
Nursing: Must have 4 years of nursing experience or a combination of inpatient coding with at least 2 years of CDI experience.
HIM: 4 years of medical record review experience in inpatient coding/auditing or Quality, or Case Management, or CDI.
Know ICD-10, Complications/Comorbid Conditions, and how each sets the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.

Responsibilities

Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
Performs review of record to establish complete, accurate documentation of patient condition and treatment. When appropriate, update working DRG.
Promotes and obtains documentation for clinical conditions or procedures. This supports the severity of illness, risk of mortality, and complexity of care through interaction with practitioners.
Demonstrates the ability to recommend proficient queries to practitioners or support staff about missing, unclear, or conflicting health record documentation. Escalates provider non-responses or inappropriate responses for reconciliation.
Collaborates with Health Information Management coders and Clinical Documentation Improvement Specialists. Reconciles potential documentation and coding opportunities, including examining working versus final coded DRG. Works with interdisciplinary teams, including physicians, mid-level providers, nurses, Patient Safety, and Health Care Improvement.
Collaboratively works with interdisciplinary teams to validate accurate DRG assignments.
Develops and provides ongoing education about documentation opportunities to practitioners, Health Information Management Coders, and Clinical Documentation Improvement Specialists. Promotes related education to allied health professionals, Administration, Utilization Review, and Comprehensive Care. Focuses on documentation's effect on SOI, ROM, CMI, reimbursement, and data reporting.
Formulates, interprets, and examines data to improve documentation practices. The focus could include DRG impact, SOI/ROM, or physician profiles.