About the job
Job Description
The primary purpose of this position is to facilitate the appropriate clinical documentation to ensure that level of services and acuity of care are accurately reflected in the medical record.
Responsibilities
Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
- Performs admission reviews for specific patient populations using clinical documentation guidelines.
- Assists in medical screening process by documenting appropriateness of patient admission, working DRG & expected LOS info on worksheet and computer system as appropriate.
- Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on worksheet or in system.
- Utilizes clinical skills to identify documentation opportunities that reflect severity of iIIness, acuity and resource consumption.
- Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified.
- Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
- Reviews medical record every 24-48 hours as appropriate.
- Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate.
- Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment.
- Communicates with physician to ensure that request for documentation has been noted.
- Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart.
- As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services.
- Follows established process for follow-up reviews and physician communication.
Reviews clinical issues with coding staff to assign working DRG using software.
- Collaborates with coding staff as needed to determine appropriate DRG and required documentation.
- Utilizes coding staff knowledge of Coding Clinics.
- Provides clinical expertise and references to the coding staff.
- Follows established guidelines for reconciling final coded DRG with the working DRG assigned at the time of discharge.
Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance.
- Attends and participates in educational conferences.
- Participates in concurrent performance improvement activities and on- going MR review activities.
- Reviews data in conjunction with established benchmarks.
Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance.
- Performs other related job duties as requested. (Where Applicable)
Qualifications
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: RN required, BSN preferred.
YEARS OF EXPERIENCE: 5 years in med/surg, critical care, intensive care or emergency room care preferred
REQUIRED SKILLS AND KNOWLEDGE:
- Must possess and consistently demonstrate strong interpersonal communication skills.
- Ability to interact well with physicians and other members of allied health care team, including HIM coders.
- Must be computer literate or willing to learn how to use computer applications relative to job.
LICENSES & CERTIFICATIONS:
Registered Nurse (RN)