Department: Health Information Management
Hours per week: 40, eligible for benefits
Shift: Monday - Friday 8am to 5pm, some flexibility dependent on providers, but always Monday through Friday
Ensures overall quality and completeness of the clinical documentation. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, multidisciplinary care givers and the Health Information Management coding staff to ensure that clinical severity is captured for the level of service rendered and support appropriate reimbursement for all patients with a DRG-based payer (Medicare, Medicaid, etc.). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates/trains all members of the care team on the Clinical Documentation Improvement program/processes.
Assign and monitor DRG assignment, DRG reports and tracking areas for performance improvement throughout the patient's hospital stay.
Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
Collaborates with HIM coding staff, manager and coding education and compliance educator to assist in the understanding to promote complete and accurate clinical documentation and correct negative trends.
Communicates with physicians, nurse practitioners, case managers, coders and other members of the interdisciplinary team members to facilitate comprehensive medical record documentation to reflect treatment, decision and medical documentation.
Facilitates modification to clinical documentation to support the clinical picture, risk of mortality and severity of illness rendered to all inpatients.
Queries physicians regarding missing, unclear or conflicting health documentation
General Work Experience - Minimum of three years HIM experience in acute care coding preferred. Must have excellent computer skills and skills in Microsoft Office. Must have excellent verbal and written communication skills. Prefer nursing education with a RHIA/RHIT. Must have a CCA or CCS AHIMA coding credential within 1 year of position date and must maintain active certification.
Required Experience: 3-5 years Health Information Management or Nursing; Peferred Experience: 3-5 years Health Information Management or Nursing.
Required: Associates or Bachelors.
Required: RHIT/RHIA or Registered Nurse.
Preferred Certified Coding Specialist (CCS). Preferred Certified Documentation Improvement Practitioner (CD
HEALTHeCAREERS Network - 16 months ago
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