Clinical Doc Improv Spec 2

Baylor Scott & White Health•Remote,

40d

About The Position

Performs patient record reviews to ensure complete, accurate, and timely documentation of the conditions supporting hospitalization and treatment. Presents queries to physicians to clarify unclear or incomplete documentation. Requires knowledge of ICD-10 and Complications/Comorbid Conditions, including their roles in the final Diagnosis Related Group (DRG), Severity of Illness (SOI), and Risk of Mortality (ROM). The role works with practitioners and interdisciplinary teams to improve documentation, validate DRG assignments, reconcile documentation and coding opportunities, and educate stakeholders about the effects of documentation on SOI, ROM, Case Mix Index (CMI), reimbursement, and data reporting. It also examines data to help improve documentation practices.

Requirements

Bachelor's degree in nursing, Health Information Management, or Health Informatics.
Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
Must hold one of the following 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 pathway: 4 years of nursing experience, or a combination of inpatient coding and at least 2 years of CDI experience.
HIM pathway: 4 years of medical record review experience in inpatient coding/auditing, Quality, Case Management, or CDI.
Knowledge of ICD-10 and Complications/Comorbid Conditions and how they affect the final DRG, SOI, and ROM.

Responsibilities

Facilitate accurate, timely, and complete documentation of medical conditions and treatment in patient records.
Review patient records to establish complete and accurate documentation of the patient's condition and treatment; update the working DRG when appropriate.
Promote and obtain documentation for clinical conditions or procedures to support severity of illness, risk of mortality, and complexity of care through interaction with practitioners.
Recommend queries to practitioners or support staff about missing, unclear, or conflicting health record documentation, and escalate provider non-responses or inappropriate responses for reconciliation.
Collaborate with Health Information Management coders and Clinical Documentation Improvement Specialists to reconcile documentation and coding opportunities, including comparing working and final coded DRGs.
Work with interdisciplinary teams, including physicians, mid-level providers, nurses, Patient Safety, and Health Care Improvement.
Collaborate with interdisciplinary teams to validate accurate DRG assignments.
Develop and provide ongoing education about documentation opportunities to practitioners, Health Information Management coders, Clinical Documentation Improvement Specialists, allied health professionals, Administration, Utilization Review, and Comprehensive Care.
Examine and interpret data to improve documentation practices, including DRG impact, SOI/ROM, and physician profiles.