Clinical Documentation Specialist
Hennepin Healthcare
1 hour ago
Full-time
Remote
Worldwide
Registered Nurse
JOB DETAILS
Department: Clinical Documentation Improvement
FTE: 1.00 (80 hours per pay period)
Workdays: Monday - Friday
Shift(s): Days
Shift Length: 8 hours
Location: Remote*
*Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
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.
RESPONSIBILITIES
Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP’s) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
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 whenever possible
Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notifies appropriate staff personnel for further review
Conducts post discharge reviews and reconciliation of DRG assignment and baseline DRG, ensuring correct outcome for all coding queries responses
Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided. This may require the use of computer software and developing education using software such as PowerPoint
Applies federal and state documentation and coding (ICD-10-CM/PCS) 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 CDI leadership, as well as the inpatient coding management and staff as needed
Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
Be able to prepare and provide service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
Participates in educational programs and in-services in order to maintain clinical documentation requirements, knowledge and ICD- 10-CM /PCS coding requirements
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 Medical Staff, Advanced Practice Practitioners (APP’s), other provers and team members
Must be able to work with minimal supervision and assist others in completing the work of the team. 18. 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
Certification/License Required: Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association.
-OR-
Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN
Preferred Qualifications:
Bachelor’s degree with some dental focus and business background
Knowledge/ Skills/ Abilities:
Knowledge of specialty healthcare and dentistry
Knowledge of dental insurance and financial coordination
Excellent communication skills in person and on telephone
Excellent customer service skills
Knowledge of medical terminology
Advanced computer skills
Ability to work effectively with others
Ability to work independently and efficiently
Exceptional time management skills
Ability to adapt to changing priorities and regulations
Essential knowledge of dental insurance coverages and programs,including prior authorization, payment plans, and collecting co-pays or payments
Strong organizational skills
Department: Clinical Documentation Improvement
FTE: 1.00 (80 hours per pay period)
Workdays: Monday - Friday
Shift(s): Days
Shift Length: 8 hours
Location: Remote*
*Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
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.
RESPONSIBILITIES
Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP’s) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
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 whenever possible
Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notifies appropriate staff personnel for further review
Conducts post discharge reviews and reconciliation of DRG assignment and baseline DRG, ensuring correct outcome for all coding queries responses
Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided. This may require the use of computer software and developing education using software such as PowerPoint
Applies federal and state documentation and coding (ICD-10-CM/PCS) 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 CDI leadership, as well as the inpatient coding management and staff as needed
Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
Be able to prepare and provide service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
Participates in educational programs and in-services in order to maintain clinical documentation requirements, knowledge and ICD- 10-CM /PCS coding requirements
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 Medical Staff, Advanced Practice Practitioners (APP’s), other provers and team members
Must be able to work with minimal supervision and assist others in completing the work of the team. 18. 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
Certification/License Required: Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association.
-OR-
Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN
Preferred Qualifications:
Bachelor’s degree with some dental focus and business background
Knowledge/ Skills/ Abilities:
Knowledge of specialty healthcare and dentistry
Knowledge of dental insurance and financial coordination
Excellent communication skills in person and on telephone
Excellent customer service skills
Knowledge of medical terminology
Advanced computer skills
Ability to work effectively with others
Ability to work independently and efficiently
Exceptional time management skills
Ability to adapt to changing priorities and regulations
Essential knowledge of dental insurance coverages and programs,including prior authorization, payment plans, and collecting co-pays or payments
Strong organizational skills