Specialist-Clinical Documentation III RN

Job Summary

Evaluates the day to day documentation practices of the Medical Staff and healthcare team on a complex patient population, and offers education and recommendations in accordance with the Clinical Documentation Program. Provides clinical expertise in the documentation and coding of diagnoses and procedures; stays abreast of coding and reimbursement changes; promotes quality coding and serves as a resource to the coding staff. Reports to the Corporate Clinical Documentation Manager. Performs other duties as assigned.

Responsibilities

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Performs Quality mortality reviews to ensure documentation accuracy and to maximize the severity of illness and risk of mortality.
• Performs reviews for risk adjustment model indicators such as CMS quality measures, present on admission, pay for performance, value based purchasing, and other national reporting initiatives. Also works with hospital performance improvement and quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC’s) reductions.
• Improves documentation specificity, and acuity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via clarifications, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.
• Works independently in a "hybrid" work mode - working both in-facility as well as remotely and has multi-facility/entity responsibility.
• Serves as a member of the clinical team that supports specific Hospital and System initiatives and aids HIM Department in meeting their time requirement of the coding and billing revenue cycle.
• Must demonstrate knowledge of the principles of disease definitions and natural history, possess the ability to assess data reflective of the patient's clinical status, interpret the appropriate information needed to identify each patient's acuity and severity of illness.
• Establishes the working DRG assignments. When applicable, collaborates with coding liaison to determine accurate final DRG assignment.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.