SPCLST CLIN DOC-HIM-CODING-M (25045)
IOWA HEALTH - DES MOINES - Des Moines, IA

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The Clinical Documentation Specialist (CDS) performs concurrent review of targeted inpatient records to insure complete and accurate clinical documentation to reflect the appropriate level of severity of illness and risk of mortality for outcomes reporting and for hospital reimbursement under prospective payment. This involves communication in oral and written form to physicians and other clinicians during the rounding process on the unit in order to insure that all the key elements are documented in the record for purposes of reporting the correct severity and risk-adjusted DRG (CMS DRGs, MS-DRGs and APR-DRGs). The key elements used for DRG assignment are the admitting diagnosis/principal diagnosis, co-morbidities/complications and any significant procedures. The CDS will also serve as a resource on clinical documentation to other departments reviewing the concurrent record such as Case Management and Clinical Quality. The CDS will provide in-services as needed to physicians and hospital staff.

Qualifications/Experience

Valid Iowa license as Registered Nurse. Conceptual knowledge of hospital ICD-9-CM coding guidelines, UHDDS data reporting requirements and DRG methodology preferred but not required. Minimum of 5 years of recent clinical experience demonstrating ability to think critically and to make clinical assessments based on patient information provided in the clinical setting OR 5 years experience in Clinical Documentation Improvement (DRG validation) in an acute care setting. This position may be assigned a specific mission to address in an emergency situation to assist in disaster response and recovery as part of the IH-DM Hospital Emergency Incident Command System. Situations of a critical nature may require an individual to perform multiple tasks until additional support can be obtained.
Job Information

SPCLST CLIN DOC-HIM-CODING-M

(25045)

Company:
IOWA HEALTH - DES MOINES

Facility / Division:
SUPPORT

Account:
MEDICAL RECORDS SERVICES

Department:
HIM CODING

Employment Status:
FULL-TIME REGULAR (FTR)

FTE:
Full-Time (FTE: 1.00, Hours: 80)

Shift:
Day Shift; Monday - Friday

Salary Range:
$ 23.39 - $ 36.25

Location:
IMMC MAIN CAMPUS

1200 PLEASANT ST

DES MOINES, IA 50309

Primary Duties and Responsibilities

The Clinical Documentation Specialist (CDS) performs concurrent review of targeted inpatient records to insure complete and accurate clinical documentation to reflect the appropriate level of severity of illness and risk of mortality for outcomes reporting and for hospital reimbursement under prospective payment. This involves communication in oral and written form to physicians and other clinicians during the rounding process on the unit in order to insure that all the key elements are documented in the record for purposes of reporting the correct severity and risk-adjusted DRG (CMS DRGs, MS-DRGs and APR-DRGs). The key elements used for DRG assignment are the admitting diagnosis/principal diagnosis, co-morbidities/complications and any significant procedures. The CDS will also serve as a resource on clinical documentation to other departments reviewing the concurrent record such as Case Management and Clinical Quality. The CDS will provide in-services as needed to physicians and hospital staff.

Qualifications/Experience

Valid Iowa license as Registered Nurse. Conceptual knowledge of hospital ICD-9-CM coding guidelines, UHDDS data reporting requirements and DRG methodology preferred but not required. Minimum of 5 years of recent clinical experience demonstrating ability to think critically and to make clinical assessments based on patient information provided in the clinical setting OR 5 years experience in Clinical Documentation Improvement (DRG validation) in an acute care setting. This position may be assigned a specific mission to address in an emergency situation to assist in disaster response and recovery as part of the IH-DM Hospital Emergency Incident Command System. Situations of a critical nature may require an individual to perform multiple tasks until additional support can be obtained.

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