Clinical Documentation and Compliance Specialist

Presbyterian Healthcare Services

3d • $62,400 - $95,306 • Remote

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled Clinical Documentation and Compliance Specialist. This position is expected to assist medical staff providers with documentation in the medical record. Will be responsible to review physician documentation daily; keep track of patient diagnosis and procedures to reflect the level of service provided. Will work independently and must be able to develop, schedule and prioritize the workload to ensure all work is completed. Must be flexible to assist with coverage issues and a team player in consultation with other reviewers and HIM coders. Excellent communication skills are essential for daily interaction and collaboration with physicians and staff to ensure that clinical information in the medical record is present and accurate to support that the appropriate clinical severity is captured for the level of service rendered. This position may encounter resistance due to the perception that information is already adequately documented in the medical record. It requires experience and confidence to address all types of clinical documentation issues and regulatory requirements. The individual must be assertive and tactful to obtain medical staff cooperation

Requirements

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required.
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required.
• Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
• Experience with database, spreadsheet and word process required.
• Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential.

Nice To Haves

• 5 years experience in critical care (CCU, ICU)

Responsibilities

• Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated.
• Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions and documents findings.
• Works collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile.
• Assist physicians with documentation requirements to support medical necessity for hospital and physician billing.
• Interprets clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary, for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate.
• Initiates communication to physicians, providers, verbally or utilizing the appropriate prompter/query tools, in order to obtain more specific principal diagnosis or co morbidities and complications.
• Solicit clarification of existing documentation in the medical record that support patient severity of illness.
• Acts as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
• Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation.
• Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-10, CPT, HCPCS and APC updates and changes. This includes but is not limited to CMS, JCAHO, Nursing Standards of Practice, etc.
• Maintains up-to-date working knowledge of all PHS coding and documentation IT applications.
• Maintains current knowledge of Nursing Practice through seminars, workshops, publications, etc.
• Conducts training classes in areas of coding, documentation and compliance for physicians and other providers. This includes preparation of training materials, educational audits and answering situational questions.
• Serves as a liaison to other departments, providing clinical expertise and consultation.
• Utilizes monitoring tools to track defined measures for progress of documentation accuracy

Benefits

• All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

What This Job Offers

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