RN, OP Clinical Doc Improvement Specialist, FT

1. Education / Credentials

Current Arkansas licensure as a registered nurse; Bachelor of Science ( BSN ) preferred or CCS/RHIA/RHIT with ten years of inpatient coding experience.

2. Training and Experience

Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting

3. Job Knowledge: Clinical expert with at least 2 years recent inpatient experience

Excellent verbal and written communication skills

Proficiency in organization and planning

Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and internet search

Ability and willingness to seek out and accept change

Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice

Knowledge of federal, state and private payer regulations

4. Safety Sensitive: NO

In the interest of protecting the health and safety of all patients, associates, and guests, Unity Health has classified some positions as “safety sensitive.” A “safety sensitive” position is any job position in which impaired performance could result in harm to the health and/or safety of self or others. Any associate that is actively engaged in the use of medical marijuana, even if in possession of a valid medical marijuana card, will be excluded from employment in a “safety sensitive” position.

Description

The Outpatient Clinical Documentation Improvement Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients.

The CDIS will

• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans, authorization of insurance for procedure performed and notification to Insurance if this changes
• Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures to support the procedure performed
• Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record to support level of billing
• Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
• Gather and analyze information pertinent to documentation findings and outcomes