Clinical Documentation Integrity Specialist

Owensboro Health

2d

About The Position

Collaborates with physicians, nursing staff, support staff, ancillary staff, Medical Director of Case Management, and Health Information Management (HIM) coding staff to improve quality and completeness of documentation related to care provided and coded.

Requirements

• Requires critical thinking skills and decisive judgment.
• Must be able to work in a stressful environment and take appropriate action.
• A minimum of 4 years' relevant experience required
• Bachelor’s degree or higher in Nursing required upon hire
• RN - Licensed as a Registered Nurse.
• Eligible to practice nursing in the State of Kentucky required upon hire

Responsibilities

• Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis-Related Group (DRG) based payer.
• Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
• Serves as a resource for physicians to help link coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk or mortality, and final code assignment.
• Identifies the most appropriate principle diagnosis, co-morbid conditions, complications of care, and procedures on a concurrent basis utilizing International Classification of Diseases (ICD-10-CM) Official Guidelines for Coding and Reporting.
• Confers with physicians one-on-one or by written documentation clarification (query) for: a) clinical indicators of a diagnosis but no documentation of the condition b) clinical evidence for a higher degree of specificity or severity c) a cause-and-effect relationship between two conditions or organism d) an underlying cause when admitted with symptoms e) only the treatment is documented (without a diagnosis documented) f) present on admission (POA) indicator status.
• Monitors and evaluates effectiveness of concurrent chart review and documentation clarification outcomes.
• Ensures accurate data entry to maintain the integrity of outcomes and effectiveness of overall program.
• Reviews final DRG assigned by HIM coding staff to ensure accuracy and that no further opportunity exists for documentation clarification.
• Educates all members of the patient care team on documentation guidelines on an on-going basis.
• Provides physician on-going education related to CMS rules and regulations pertaining to documentation in the health.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level