Clinical Documentation Specialist - Hospice of Cincinnati

TriHealth, Inc. • Blue Ash, OH

46d

About The Position

Concurrently review hospice patients' medical records for accuracy and completeness of documentation throughout enrollment in hospice services. Ensure accuracy and completeness of clinical information within the chart by analyzing for potential gaps in documentation related to the determination of terminal illness, physician certification, and quality core measures. Analyze clinical documentation to support billable level of care to facilitate accurate claims submission. Prepare and review medical records in response to ADRs. Facilitate improvement in clinical documentation through education and extensive interaction with HOC IT, Business Office, Quality Department, nursing managers, and staff. Systematic development and implementation of educational opportunities for physicians, nursing staff, and all other members of the health care team, in collaboration with the Education and IT departments. Facilitate completion and submission of the Hospice Item Set (HIS) to CMS as required within appropriate timeframes. Complete HIS education and training with managers and nursing staff.

Requirements

• Bachelor's Degree in Nursing (Required)
• 4 - 5 years experience Clinical in Nursing (Required)
• 2 - 3 years experience Clinical Hospice inpatient and/or Home care experience (Required)
• Basic keyboarding and Microsoft office
• Knowledge of related hospice software
• Knowledge of Hospice Conditions of Participation and Joint Commission requirements for hospices
• Registered Nurse

Responsibilities

• Collaborate with clinical managers to assure documentation corrections are made. Educate physicians, nursing staff, and other healthcare staff in clinical documentation guidelines related to errors in medication orders, documentation of medical orders, justification of hospice services and levels of care, synchronization and locking.
• Collaborate with the IT department to ensure that documentation from all clinical areas is captured in the Electronic Medical Record
• Facilitate completion and submission of the Hospice Item Set (HIS) to CMS as required within appropriate timeframes. Complete HIS education and training with managers and nursing staff as needed.
• Facilitate the accuracy of the determination of terminal illness, terminal diagnosis, and physician certification by performing audits of new admissions/continued enrollment, using clinical documentation guidelines, LCDs, and Hospice Conditions of Participation.
• Review medical records and assemble for ADRs when requested. Perform audits for special needs when requested by clinical and/or quality departments. Establish a process to respond to RACs (Recovery Audit Contractors) from Medicare.
• Review medical records to assure accurate level of care, completeness of plan of care, and to support the billable level of care for claims submission.

What This Job Offers

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