Clinical Documentation Specialist II

Prisma Health • Greenville, SC

151d • Onsite

About The Position

Inspire health. Serve with compassion. Be the difference. Job Summary Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of clinical documentation. This is accomplished by medical record review, query process, and reconciliation process. Participates in the development and delivery of clinical documentation education for providers and health care team members as needed. Serves as preceptor, education resource and second level reviewer for documentation and query justification. May be called on to validate query impact for team. Accountabilities Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation. (50%) Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (15%) Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%) Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification. (10%) Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%) Fulfils all other duties and responsibilities of a CDIS I (5%) Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive. Minimum Education Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field. Minimum Experience Four (4) Adult medical/surgical/critical care/ER/PACU nursing coding or related field Clinical documentation improvement experience (2 years) Required Certifications/Registrations/Licenses One of the following certifications: RN, RHIA, RHIT, CCS, or CIC CCDS/CDIP Other Required Experience Computer skills, keyboarding. Strong communication skills with ability to interact with providers and remain tactful. General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems. Work Shift Day (United States of America) Location Corporate Facility 7001 Corporate Department 70017540 Clinical Documentation Integrity Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health. Prisma Health is the largest not-for-profit health organization in South Carolina, serving more than 1.2 million patients annually. Our 32,000 team members are dedicated to supporting the health and well-being of you and your family. Our promise is to: Inspire health. Serve with compassion. Be the difference.

Requirements

• Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.
• Four (4) Adult medical/surgical/critical care/ER/PACU nursing coding or related field Clinical documentation improvement experience (2 years)
• One of the following certifications: RN, RHIA, RHIT, CCS, or CIC CCDS/CDIP
• Computer skills, keyboarding.
• Strong communication skills with ability to interact with providers and remain tactful.
• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems.

Responsibilities

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation. (50%)
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (15%)
• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification. (10%)
• Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
• Fulfils all other duties and responsibilities of a CDIS I (5%)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees