Clinical Documentation Improvement Specialist

South Shore Health • Weymouth, MA

2d • Onsite

About The Position

Under the general supervision of the Manager of Clinical Documentation, this position will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness. The documentation specialist is on–site and available five (5) days a week.

Requirements

• Excellent communication and critical thinking skills.
• Demonstrates leadership qualities such as the ability to motivate, teach, and facilitate individuals and groups on reaching the objectives of the program.
• Basic personal computer skills required.
• RN-Registered Nurse - Board of Registration in Nursing (Massachusetts)

Nice To Haves

• Working knowledge of Medicare and Blue Cross inpatient reimbursement and coding structures is desired.
• Knowledge of care delivery documentation systems and related medical record documents desired.
• Knowledge of age-specific needs and the elements of disease processes and related procedures preferred.
• Self-motivated, innovative individual who has the ability to work in a time oriented environment.
• Prefer experience interacting with physicians and concurrent review with clinical records.

Responsibilities

• Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness.
• Produces worklists from Meditech daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission.
• Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet.
• Identifies need to clarify documentation in records and initiates assertive communication with physician or other care provider by using the most appropriate communication method for that individual – physician documentation request, face to face contact, phone call, etc.
• Inputs current DRG into Meditech for all Medicare patients daily.
• Inputs and reconciles queries on excel datasheet daily.
• Provide information and education as necessary to physicians and other care providers specific to DAP.
• Presents overview of program to new physicians and other care providers at orientation.
• Follows up with new physicians who document in medical records in a one to one meeting.
• Provides ongoing information/education as necessary to physicians and other care providers not responding to documentation requests.
• Assists in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation.
• Continual medical staff education as a proactive measure.
• Maintains a collaborative working relationship with team and with the Health Information Management department staff.
• Performs focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness.
• Performs focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness.
• Shares pertinent coding and DRG reference materials (e.g. coding clinics).
• Shares pertinent clinical information (e.g. new drugs/treatments).
• Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action.
• Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis.
• Identifies trends or potential problems and assists in developing action plans to address.
• Tracks and provides regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.
• Participates in organizational surveys that evaluate staff perception of safety.
• Seeks and participates in educational opportunities to improve job skills and program.
• Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.
• Identifies annually at least one implementable idea to improve patient, staff or environmental safety.
• Successfully answers safety questions in annual mandatory education program.
• Understands roles/responsibilities during hospital codes.
• Adheres to respiratory etiquette guidelines.
• Participates in continued learning and possesses a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
• Embraces technological advances that allow us to communicate information effectively and efficiently based on role.
• Other duties as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed