MEDICAL CODING MODERNIZATION SPECIALIST/CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST (ON-SITE) (25874)

LTSi - Laredo Technical Services, Inc. • Bethesda, MD

3d • $34 - $37 • Onsite

About The Position

Provides clinically based concurrent and retrospective review of patient medical records to assess and procure accurate and complete documentation of patient diagnosis and procedures. The specific goal is to facilitate appropriate provider documentation of all patient conditions, treatments and interventions to accurately reflect quality of care, Severity of Illness (SOI) and Risk of Mortality (ROM) to support correct coding, reimbursement and quality initiatives.

Requirements

• A minimum of one of the following: Credentialed CDI professionals (e.g. Certified Documentation Improvement Practitioners (CDIP), Certified Clinical Documentation Specialists (CCDS).
• Participate in continuing education programs, professional organizations (AHIMA, ACDIS, etc.) and attend seminars to maintain CDIS/Clinical competency and growth, maintain current and proper national certification(s) requirements for this position at no expense to the government.
• A minimum of five years of experience as a CDIS in a critical care environment.
• Exceptional written and verbal communication skills along with highly developed organization skill, critical thinking and analytical skills.
• Ability to proactively form positive, collaborative relationships with physicians, residents/interns, mid-level clinicians, coders and other healthcare professionals.
• Knowledge of Healthcare coding regulations and documentation requirement.

Nice To Haves

• Experience with criteria-based chart review, such as Utilization Management, Case Management, Managed Care, Quality Improvement preferred.

Responsibilities

• Contractor will be on-site 5 days a week, 8 hours a day, Monday through Friday. Must work during core PAD hours (0700-1700). Telework may be authorized at the discretion of the COR.
• Must attend scheduled auditing training meetings.
• Provide a monthly log of queries and their outcome to PAD Leadership.
• Review inpatient medical records on a daily basis, concurrent with patient stay, 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.
• Utilize the designated industry and/or department clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Conduct follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented. Must reference DHA policy for compliance; states 72 hours to query providers.
• Participate or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with the multidisciplinary healthcare team.
• 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 accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.
• Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician-specific data information.
• Enhance expertise in query development, presentation, and standards (including understanding of published query guidelines and practice expectations for compliance).
• Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Aid in identification and proper classification of complication codes (patient safety indicators/hospital- acquired conditions) by acting as an intermediary between coding staff and medical staff.
• Participate on departmental and hospital committees and assigned task forces, including denials management.
• Comply with HIPAA and code of conduct policies.
• Interact with appropriate resources that support growth and education of the CDI team.
• Submit monthly report on activities done for the month, e.g. training provided and feedback.

Benefits

• Health, Dental and Vision
• 401(k)
• Vacation
• Sick Leave
• 11 Paid Federal Holidays including: New Year’s Day Martin Luther King, Jr. Day Presidents Birthday Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Day Christmas Day

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 1-10 employees