Outpatient Clinical Documentation Analyst

Yale-New Haven Health • New Haven, CT

65d

About The Position

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The Outpatient Clinical Documentation Specialist I RN facilitates modifications to clinical documentation through extensive concurrent interactions with physicians and other clinicians to provide an accurate picture of true acuity and clinical condition of the patient, highest level of specificity, medical necessity and the documentation support the services provided to the patient in the outpatient setting. The specialist shall review and evaluate selected patient 's medical records for overall quality and completeness. The specialist will educate physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues, and relevant quality and performance improvement opportunities. The specialist will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels. This individual uses clinical expertise and leverages past work clinical experience in addition to familiarity with coding guidelines, DGs, reimbursement methodology, compliant coding and billing practices, payer policies, coverage determinations, denial data to identify opportunities that are compliant and appropriate to achieve maximum results. This individual also supports other team members, shares knowledge and role models the professional standards of behavior.

Requirements

• Registered Nurse with active license, BSN strongly preferred.
• At least three (3) years of recent acute care nursing experience required.
• Clinical expertise required.
• RN license required.
• Must obtain a CCS or COC coding credential within 12 months of hire.
• Must obtain and hold CCDS-O (Certified Clinical Documentation Specialist-Outpatient through acdis upon reaching eligibility after two years in the position.

Nice To Haves

• Coding credential through AAPC or AHIMA preferred.

Responsibilities

• Performs focused clinical medical record reviews and of discharged outpatient patients to identify the most appropriate diagnosis and the medical record documentation supports services rendered.
• Completes the initial review within 24-48 hours of discharge.
• Educates internal staff on clinical documentation documentation and coding guidelines.
• Develops and conducts ongoing training, education to ensure charts have all the necessary documentation to support the most accurate coding for services rendered.
• Develops and supports strong professional relationships with team members, coding staff, clinical and operational department leadership, and medical providers across the system.
• Utilizes a compliant query process per guidelines and policy when conducting all queries.
• Works collaboratively with physician and nursing leadership to ensure positive program outcomes.
• Provides in person CDI training to providers one on one, during staff meetings or department meetings.
• Creates custom dashboards, score cards, and messages department performance metrics and CDI opportunities on a regular basis.
• Assists in other monitoring activities, special department projects or other needs as determined by the department manager.
• Provides ongoing CDI team learning opportunities through sharing of professional knowledge.
• Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
• Supports and implements quality measures as identified by department manager.
• Identities opportunities of performance improvement and leads initiatives from initial assessment through post implementation monitoring.
• Performs other duties as needed to support program and its initiatives.

What This Job Offers

• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees