SUMMARY
The Clinical Documentation Specialist (CDS)/Coder III is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. The CDS/Coder III abstracts and codes the diagnostic and procedural information for Inpatient Services and Surgery medical records utilizing the current version of International Classifications of Diseases in accordance with regulatory agencies and hospital specific guidelines. The CDS/Coder III enters the coded data and other abstracted data from the medical record into the electronic information system. This position assumes primary responsibility for clarifying ambiguous documentation, DRG optimization with the primary role in assisting medical staff members with improving quality of documentation and serves as a mentor to all level of Coders and CDIs. Participates in chart review projects as assigned.
REQUIREMENTS
RESPONSIBILITIES AND DUTIES:
- Understands and is able to incorporate hospital philosophies into the department’s operational plan and goals and assures staff members understand philosophies.
- Demonstrates expertise in the clinical documentation, serving as a resource, and participates in problem-solving opportunities.
- Contributes ongoing department information, sharing and promoting knowledge and skill development.
- Comprehends and adheres to industry standards and regulatory requirements: including, but not limited to, TJC, HFAP, CMS, Title XXII, HIPAA, medical staff regulations, and hospital policies.
- Demonstrates knowledge of resource management plans in an effort to decrease resource consumption, while adequately maintaining effective operations.
- Demonstrates working knowledge of information systems related to job duties.
- Possesses an awareness of reimbursement processes, including how different payers use the coded data to determine reimbursement. Aware of Medicare reimbursement methodology for inpatient services as it pertains to clinical documentation and coding.
- Possesses an awareness of hospital processes, understanding inter-department relationships, promoting collaborative effort and consideration prior to instituting changes, deletions or additions of processes.
- Proficiency in utilization of computer-based tools in retrieving and maintaining inpatient census data, coding and audit tracking.
- Reviews inpatient medical records for identified payer populations as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
- Ensures that clinical documentation reflects the level of service rendered to patients is complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services.
- Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff.
- Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 48 hours of admission, on the working days.
- Manages the concurrent medical record review for clinical documentation improvement throughout the hospital stay. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical record.
- Regularly participates in scheduled case management and hospitalist meetings and actively exchanges information pertaining to clinical documentation to support intensity of services and level of acuity of the patient.
- Other duties as needed.
EDUCATION & EXPERIENCE REQUIREMENTS:
- Inpatient CDI plus.
- Outpatient CDI experience consider
- ED CDI who has working experience on admission criteria including medical necessity, quality measure, E&M level
- Foreign Medical Graduate, PA, RN, LVN, RHIT or CCS with current valid license/certification and relevant education.
- CCS Certification preferred
- CDIP and/or CCDS Certification preferred
SKILLS & ABILITIES REQUIREMENTS:
- Ability to describe a quality improvement in problem solving process and how its use assists in reaching improving clinical documentation and/or organizational quality improvement goals.
- Able to verbalize at least one departmental or hospital wide improvement initiative that has occurred within the last 12 months.
- Cooperates with others in the improvement of services offered at our institution. Continually makes recommendations that assist in the improvement of services.
PHYSICAL REQUIREMENTS:
- Body Positions: Sitting and standing for prolonged periods.
- Body Movements: Arm and hand dexterity.
- Body Senses: Must have command of close and distant sight, color perception and hearing.
- Strength: Ability to lift and move up to 25-pounds.
