Clinical Documentation Specialist - Hospice of Cincinnati
About The Position
The Clinical Documentation Specialist concurrently reviews hospice patients’ medical records for accuracy and completeness throughout enrollment in hospice services. The role analyzes clinical documentation for gaps related to determination of terminal illness, physician certification, and quality core measures, and supports accurate billable levels of care and claims submission. It also prepares and reviews medical records in response to Additional Documentation Requests (ADRs), supports responses to Recovery Audit Contractors (RACs), and facilitates improvement in clinical documentation through education and collaboration with hospice operations, IT, the Business Office, Quality, nursing managers, and staff. The specialist facilitates timely completion and submission of the Hospice Outcomes and Patient Evaluation (HOPE) to CMS and provides HOPE education and training to managers and nursing staff. The role supports compliance with Hospice Conditions of Participation, Joint Commission requirements, and applicable clinical documentation guidelines. This is a full-time, day-shift position at Hospice of Cincinnati in Blue Ash, with no weekend, holiday, or on-call commitment.
Requirements
- Bachelor’s degree in Nursing, Healthcare, Business, or a related field.
- Four to five years of clinical nursing experience.
- Two to three years of clinical hospice inpatient and/or home care experience.
- Basic keyboarding and Microsoft Office skills.
- Knowledge of related hospice software.
- Knowledge of Hospice Conditions of Participation and Joint Commission requirements for hospices.
- Registered Nurse Ohio nursing license or Multi-State Compact nursing license.
Responsibilities
- Review hospice patients’ medical records throughout enrollment for accurate and complete documentation.
- Analyze charts for documentation gaps related to determination of terminal illness, physician certification, and quality core measures.
- Collaborate with clinical managers to ensure documentation corrections are made.
- Educate physicians, nursing staff, and other healthcare staff on clinical documentation guidelines, including medication orders, medical orders, justification of hospice services and levels of care, synchronization, and locking.
- Collaborate with the IT department to ensure documentation from all clinical areas is captured in the Electronic Medical Record.
- Facilitate timely completion and submission of HOPE to CMS, and provide HOPE education and training to managers and nursing staff as needed.
- Audit new admissions and continued enrollment to support accurate determination of terminal illness, terminal diagnosis, and physician certification, using clinical documentation guidelines, LCDs, and Hospice Conditions of Participation.
- Review and assemble medical records for ADRs when requested.
- Perform special-needs audits when requested by clinical or quality departments.
- Establish a process for responding to Medicare Recovery Audit Contractors.
- Review medical records to ensure an accurate level of care, a complete plan of care, and documentation supporting the billable level of care for claims submission.
Benefits
- Competitive shift differentials.
- Opportunities for professional growth.
- Comprehensive benefits package that may include medical, dental, and vision coverage, paid time off, retirement savings plans, and tuition reimbursement.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
