Location: Philadelphia, PA
Duration: 6 Months
Clinical Documentation Improvement Specialist facilitates and obtains appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity.
Essential Duties and Responsibilities:
- Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
- Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
- Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Supports and participates in the continuous assessment and improvement of the quality of services provided.
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
- Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
- Ability to work effectively with all departments and all levels of professionals.
- Ability to work independently or within a team structure.
- Must be very organized and possess strong communication/presentation skills
- Establish priorities
- Experience as a clinical documentation specialist
- Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines.
- Computer skills and a working knowledge of Word, Excel and Access.
- Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs,
- Strong communication, teaching and presentation skills; must be detail oriented, and possess good problem solving skills
- BS in HIM from an AHIMA accredited HIM program plus at least 5 years of HIM inpatient coding experience (pediatric-focused coding preferred) may be
- Highly desired RN with at least 5 years acute care pediatric nursing experience (e.g., ED, ICU, case management, etc.) required.