Job Description

*_SUMMARY_*

We are currently seeking a*Clinical Documentation Specialist** *to join our CDI team. This full-time role will be remote (SHIFT: Days).

*Purpose of this Position:*Under the direction of Coding and Documentation leadership, provides active concurrent review, feedback, and education to physicians and healthcare providers to improve documentation of all conditions and treatments in the inpatient medical record, to ensure an accurate reflection of the patient condition in the associated MS-DRG assignments, case-mix index, severity of illness and risk of mortality profiling and reimbursement.

Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Nevada, North Carolina, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington State, Wisconsin. Washington

* *

*_RESPONSIBILITIES_*

* Conducts initial and continued-stay concurrent reviews (every 2 days) on inpatient admissions and documents findings using the CDIS Module in 3M, denoting all key information utilized in tracking process

* Identifies all procedures and secondary diagnoses for co-morbidities/ complications and documents appropriately using the CDIS Module in 3M

* Identifies documentation issues such as quality, appropriateness, completeness, and reimbursement issues and communicates these issues to physicians and other caregivers so that immediate resolution can be made

* Queries the medical staff and other providers as necessary via written/ verbal communication to obtain accurate and complete physician documentation which reflects the severity of the patient's illness and risk of mortality, as well as documentation clarification for profiling, coding and equitable hospital reimbursement

* Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge

* Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient's stay to improve coding specificity and obtain equitable reimbursement.

* Applies federal and state documentation and coding (ICD 9 and ICD 10) guidelines to ensure physician and hospital compliance. Maintains current knowledge of coding/documentation information including the AHA's Coding Clinic publication, pharmacology, laboratory, disease processes, and new/ emerging technologies to ensure accuracy of code assignment and compliance

* Identifies documentation trends and issues and reports these to HIM Director, CDI Manager, CDI Supervisor, as well as the inpatient coding management and staff

* Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment

* Prepares and provides ongoing service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement

* Monitors changes in laws, regulations and policies that impact documentation, reimbursement and compliance

* Participates in educational programs and in-services in order to maintain and excel in clinical documentation requirements and coding skills

* Portrays a professional manner in dress and all communication skills

* Must have effective interpersonal skills to effectively interact, communicate and maintain good working relationships with all physicians and providers.

* Must be able to work with minimal supervision and assist others in completing the work of the team

* Performs other tasks as assigned

*_QUALIFICATIONS_*

/*Minimum Qualifications:*/

* Graduation from an accredited school of nursing, and two (2) years of professional nursing experience in an emergency department, medical or surgical area of an acute hospital setting

-OR-

* Graduation from an AHIMA accredited program as a Registered Health Information Administrator (RHIA) and at least three (3) years of recent inpatient coding experience

-OR-

* Graduation from an AHIMA accredited program as a Registered Health Information Technician (RHIT) and at least four (4) years of recent inpatient coding experience

-OR-

* An approved equivalent combination of education and experience

*/Preferred Qualifications:/*

* Experience in CDI activities preferred

/*License/ Certifications:*/**

* Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN)

-OR-

* Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association

**Title:** *Clinical Documentation Specialist*

**Location:** *MN-Minneapolis-Downtown Campus*

**Requisition ID:** *240055*

Job Tags

Similar Jobs