Clinical Documentation Integrity Specialist
Owensboro HealthJob Summary:
Collaborates with physicians, nursing staff, support staff, ancillary staff, Medical Director of Case Management, and Health Information Management (HIM) coding staff to improve quality and completeness of documentation related to care provided and coded.
Job Responsibilities:
Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis-Related Group (DRG) based payer.
Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes.
Serves as a resource for physicians to help link coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk or mortality, and final code assignment.
Identifies the most appropriate principle diagnosis, co-morbid conditions, complications of care, and procedures on a concurrent basis utilizing International Classification of Diseases (ICD-10-CM) Official Guidelines for Coding and Reporting.
Confers with physicians one-on-one or by written documentation clarification (query) for: a) clinical indicators of a diagnosis but no documentation of the condition b) clinical evidence for a higher degree of specificity or severity c) a cause-and-effect relationship between two conditions or organism d) an underlying cause when admitted with symptoms e) only the treatment is documented (without a diagnosis documented) f) present on admission (POA) indicator status.
Monitors and evaluates effectiveness of concurrent chart review and documentation clarification outcomes.
Ensures accurate data entry to maintain the integrity of outcomes and effectiveness of overall program.
Reviews final DRG assigned by HIM coding staff to ensure accuracy and that no further opportunity exists for documentation clarification.
Educates all members of the patient care team on documentation guidelines on an on-going basis.
Provides physician on-going education related to CMS rules and regulations pertaining to documentation in the health.
Skills and Attributes:
Requires critical thinking skills and decisive judgment.
Works under direct supervision.
Must be able to work in a stressful environment and take appropriate action.
Position Requirements:
Work Experience
A minimum of 4 years' relevant experience required
Education
Bachelor’s degree or higher in Nursing required upon hire
Licensure/Certification/Registration
RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire
Organizational Responsibilities:
Supports Owensboro Health’s Mission, Vision, Core Commitments, and business interests. Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.
Additional Job Information:
This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description.
The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.
Standard ADA Settings:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical Demands: (Office Environment)
Standing: Occasionally
Walking: Occasionally
Sitting: Frequently
Lifting 0-25 lbs.: Rarely
Lifting 25-75 lbs.: Rarely
Lifting over 75 lbs.: Rarely
Carrying 0-25 lbs.: Rarely
Carrying 25-75 lbs.: Rarely
Carrying over 75 lbs.: Rarely
Pushing/Pulling 0-25 lbs.: Frequently
Pushing/Pulling 25-75 lbs.: Rarely
Pushing/Pulling over 75 lbs.: Rarely
Climbing: Rarely
Bending/Stooping: Rarely
Kneeling: Rarely
Crouching/Crawling: Rarely
Reaching: Occasionally
Talking: Frequently
Hearing: Frequently
Repetitive Foot/Leg Movements: Rarely
Repetitive Hand/Arm Movements: Frequently
Keyboard Data Entry: Frequently
Running: Rarely
Vision: Depth Perception: Frequently
Vision: Distinguish Color: Frequently
Vision: Seeing Far: Frequently
Vision: Seeing Near: Frequently
Hazardous Drug Risk Exposure:
Risk Level: Low-Risk
Owensboro Health Core Commitments
INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.
RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.
TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.
INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.
SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.
EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.