Performs review of clinical documentation to ensure that the record appropriately reflects the services and level of care provided to the patient. Uses clinical knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the electronic medical record. Works collaboratively with a multidisciplinary team to ensure that the medical record is accurate, complete and compliant. Provides documentation, service specific requirements and clinical criteria-related education to providers and the healthcare team.
Acute Care Population: Completes initial documentation reviews of inpatient records within 24-48 hours of admission, for a specified patient population. Conducts follow-up reviews of patient records every 2-3 days to determine if queries have been answered and if any further documentation clarification is required. Works collaboratively with IP coders to reconcile all DRG’s and ensure that all quality related workflows, such as mortality, HAC, PSI and 2nd level reviews, are followed.
Ambulatory Population: Completes initial documentation reviews of ambulatory documentation prior to scheduled ambulatory visits. Analyzes clinical status of the patients, current treatment plan and past medical history and identifies potential gaps in physician documentation. Conducts follow-up reviews to determine if queries have been answered, documentation reflects the care provided and Hierarchical Condition Category’s (HCC’s) have been captured and addressed appropriately. Completes any further required follow-up with the provider. Collaborates with clinic and coding partners, as needed, to resolve provider queries.
Consistently meets established productivity targets for documentation reviews.
Proactively solicits clarification and queries providers via written and/or verbal communication to clarify medical record documentation needed to accurately reflect the patient's severity of illness/risk of mortality and to facilitate appropriate code, DRG (Diagnosis Related Group) and HCC (Hierarchical Condition Categories) capture and assignment. Utilizes analytical thinking skills in all aspects of work in order to determine when criteria is met to support diagnoses/procedures and when it is appropriate to query a physician to clarify and capture needed documentation/diagnoses.
Utilizing excellent written and verbal communication skills and clinical knowledge, prepares and provides ongoing education to providers, coders and other members of the healthcare team regarding the need for accurate, specific and complete documentation needed to appropriately document the level of care, HCC’s and services provided. This includes one-on-one and group education, in both formal and informal settings.
Maintains competence related to hospital and ambulatory CDI practices, clinical criteria, HCC documentation requirements, ICD-10-CM, ICD-10 PCS, CPT and HCPCS code assignment and coding guidelines. Stays current regarding knowledge of updated regulations, laws, and new procedures. Understands and applies the team concept. Attends all mandatory in-services and department meetings. Maintains CEU’s required for nursing licensure and CDI/Coding certification(s). Utilizes personal vehicle to travel to assigned locations. May need to work overtime and/or flexible hours, including weekends.
Specialize in one of the following areas:
Acute Care Population
Graduate of an accredited nursing program.
BSN preferred, or enrolled in BSN program.
Five years of progressive nursing experience
Hospital based and/or ambulatory CDI experience preferred.
Current IL RN licensure by the IL Dept of Professional Regulation (IDPR) or WI RN licensure by the WI Dept of Safety and Professional Services (DSPS).
Certified Clinical Documentation Specialist (CCDS), CCDS-O (Outpatient), Certified Documentation Improvement Professional (CDIP) and /or Certified Documentation Expert Outpatient (CDEO) required, or obtained within 3 years of hire. Approved hospital or professional based coding certification preferred.
The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel and talk or hear. The employee is frequently required to stand; walk; sit and reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 25 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision and ability to adjust focus. While performing the duties of this Job, the employee is regularly required to talk or hear. The employee is frequently required to walk; sit and use hands to finger, handle, or feel. The employee is occasionally required to stand; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision and ability to adjust focus. Travel to other sites may be required.