Clinical Documentation Specialist (Remote -Texas Resident) - Clinical Data

University of Texas Medical Branch (UTMB) • Galveston, TX

5d • Remote

About The Position

Scope: Responsible for the overall improvement of the quality and accuracy of medical record documentation through interaction with physicians, members of the patient care team, and hospital coding staff. Function: Ensures clinical documentation accurately reflects the appropriate level of service provided, severity of illness, and risk of mortality of each patient. Successfully facilitates the accurate representation of patient status that translates into coded data.

Requirements

• Certified Registered Health Information Administrator (RHIA), Technician (RHIT), or an associate degree in a healthcare-related discipline with Certified Coding Specialist (CCS) certification, and a minimum of 3 years of medical coding experience.
• Registered nurse (or medical school graduate) with a minimum of 3 years inpatient clinical experience, advanced clinical expertise and an extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• RN current license or RHIA/RHIT/CCS (medical school graduates are exempt from this MQ)
• Must acquire CCDS or CDIP certification within 3 years of hire
• Demonstrate excellent observation skills, analytical thinking, and problem-solving, plus good verbal and written communication.

Nice To Haves

• For nurse candidates, one year of CDI experience is highly desirable.
• Bachelor of Science in Nursing (BSN).
• CCDS or CDIP Certification.

Responsibilities

• Concurrently review inpatient admissions to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Understand the general flow of health information from medical record documentation and discharge, through coding, to billing, and finally to data reporting.
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Apply knowledge of inpatient ICD-10 coding guidelines and clinical documentation requirements to assign working MS-DRG.
• Enter review information and working MS-DRG/APR-DRG’s with associated length of stay in the shared information system, and update this information as needed to reflect any changes in the patient’s status, procedures, and treatments.
• Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation for clarification.
• Conduct follow-up of posted queries to ensure queries have been answered and physician responses have been appropriately documented.
• Educate and communicate clinical documentation opportunities in the appropriate hospital venues for staff and physician learning opportunities.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure the accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Assume responsibility for professional development by participating in workshops, conferences and/ or in-services.
• Keep current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.
• Maintain positive and open communication with physicians, members of the patient care team, case management, and hospital coding staff.
• Adhere to internal controls and reporting structure.
• Comply with all relevant policies, procedures, guidelines, and other regulatory, compliance, and accreditation standards.
• Performs related duties as required

What This Job Offers

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