Performs patient record reviews to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Present queries to physicians when needed to clarify ambiguous or incomplete documentation. Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
ESSENTIAL FUNCTIONS OF THE ROLE
Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
Performs review of record to determine complete, accurate documentation of patient condition and treatment. When appropriate, update working DRG.
Promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners.
Demonstrates ability to recommend proficient query\ies to practitioners or support staff regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed. Appropriately escalates provider non-responses or inappropriate responses for reconciliation.
Collaborates with Health Information Management coders, other Clinical Documentation Improvement Specialists and others to reconcile potential documentation and coding opportunities which might include analyzing working versus final coded DRG. Collaboratively works with interdisciplinary teams including, but not limited to physicians, mid-level providers, nurses, Patient Safety and Health Care Improvement.
Collaboratively works with interdisciplinary teams to validate accurate DRG assignments.
Develops and/or provides ongoing education and information regarding documentation opportunities to practitioners, Health Information management Coders, and other Clinical
Documentation Improvement Specialists. Promotes related education to others such as allied health professionals, Administration, Utilization Review, Comprehensive Care specific to documentation and its effect on SOI, ROM, CMI, reimbursement and data reporting.
Formulates, interprets, and analyzes data relative to opportunities to improve documentation practices. The focus of this analysis could include DRG impact, SOI/ROM, or physician profiles.
KEY SUCCESS FACTORS
Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA) and have one of the following coding certifications: CCS or CCDS or CDIP.
Must have a Bachelor's degree in Nursing, Health Information Management or Health Informatics.
Must have 4 years experience in nursing or inpatient coding with 2 years experience of CDI.
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelor's
- EXPERIENCE - 4 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION - Cert Cln Documentation Spec (CCDOCSP), Cert Coding Specialist (CCS), Cert Doc Improv Practitioner (CDIP): Must also have one of the following coding certifications: Certified Coding Specialist or Cert Clin Doc Spec orCert Doc Improvement Practitioner.
Reg Health Info Administrator (RHIA), Registered Nurse (RN): Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!
To improve the patient experience by providing health care providers; patients and their families; and others with information, education, networking opportunities, and related resources focused on best practices.