Clinical Documentation Specialist - Hospice of Cincinnati

Concurrently review hospice patients' medical records for accuracy and completeness of documentation throughout enrollment in hospice services. Ensure accuracy and completeness of clinical information within the chart by analyzing for potential gaps in documentation related to the determination of terminal illness, physician certification, and quality core measures. Analyze clinical documentation to support billable level of care to facilitate accurate claims submission. Prepare and review medical records in response to ADRs. Facilitate improvement in clinical documentation through education and extensive interaction with HOC IT, Business Office, Quality Department, nursing managers, and staff. Full time - Day Shift

Job Overview:

Concurrently review hospice patients' medical records for accuracy and completeness of documentation throughout enrollment in hospice services. Ensure accuracy and completeness of clinical information within the chart by analyzing for potential gaps in documentation related to the determination of terminal illness, physician certification, and quality core measures. Analyze clinical documentation to support billable level of care to facilitate accurate claims submission. Prepare and review medical records in response to ADRs. Facilitate improvement in clinical documentation through education and extensive interaction with HOC IT, Business Office, Quality Department, nursing managers, and staff. Systematic development and implementation of educational opportunities for physicians, nursing staff, and all other members of the health care team, in collaboration with the Education and IT departments. Facilitate completion and submission of the Hospice Item Set (HIS) to CMS as required within appropriate timeframes. Complete HIS education and training with managers and nursing staff.

Job Requirements:

Bachelor's Degree in Nursing (Required)
4 - 5 years experience Clinical in Nursing (Required) 
2 - 3 years experience Clinical Hospice inpatient and/or Home care experience (Required)
Basic keyboarding and Microsoft office 
Knowledge of related hospice software 
Knowledge of Hospice Conditions of Participation and Joint Commission requirements for hospices
Registered Nurse

Job Responsibilities:

Collaborate with clinical managers to assure documentation corrections are made. Educate physicians, nursing staff, and other healthcare staff in clinical documentation guidelines related to errors in medication orders, documentation of medical orders, justification of hospice services and levels of care, synchronization and locking. 
Collaborate with the IT department to ensure that documentation from all clinical areas is captured in the Electronic Medical Record 
Facilitate completion and submission of the Hospice Item Set (HIS) to CMS as required within appropriate timeframes. Complete HIS education and training with managers and nursing staff as needed. 
Facilitate the accuracy of the determination of terminal illness, terminal diagnosis, and physician certification by performing audits of new admissions/continued enrollment, using clinical documentation guidelines, LCDs, and Hospice Conditions of Participation. 
Review medical records and assemble for ADRs when requested. Perform audits for special needs when requested by clinical and/or quality departments. Establish a process to respond to RACs (Recovery Audit Contractors) from Medicare. 
Review medical records to assure accurate level of care, completeness of plan of care, and to support the billable level of care for claims submission.

Working Conditions:

Bending - 
Climbing - Rarely 
Concentrating - 
Continuous Learning - 
Hearing: Conversation - Consistently 
Hearing: Other Sounds - Consistently 
Interpersonal Communication - 
Kneeling - Rarely 
Lifting <10 Lbs. - 
Lifting 50+ Lbs. - Rarely 
Lifting <50 Lbs. - Occasionally 
Pulling - Rarely 
Pushing - Rarely 
Reaching - Frequently 
Reading - 
Sitting - Frequently 
Standing - Frequently 
Stooping - Rarely 
Talking - Consistently 
Thinking/Reasoning - 
Use of Hands - Consistently 
Color Vision - Frequently 
Visual Acuity: Far - Consistently 
Visual Acuity: Near - Consistently 
Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS... 
• Welcome everyone by making eye contact, greeting with a smile, and saying hello 
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist 
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS... 
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met 
• Offer patients and guests priority when waiting (lines, elevators) 
• Work on improving quality, safety, and service

Respect: ALWAYS... 
• Respect cultural and spiritual differences and honor individual preferences. 
• Respect everyone's opinion and contribution, regardless of title/role. 
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS... 
• Value the time of others by striving to be on time, prepared and actively participating. 
• Pick up trash, ensuring the physical environment is clean and safe. 
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS... 
• Acknowledge wins and frequently thank team members and others for contributions. 
• Show courtesy and compassion with customers, team members and the community