Job: Clinical Documentation Review Specialist

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Jobing Description



Location:Bremerton Hospital
Zip Code:98310
ID:1388
Department:Documentation, 87131
Shift:Days
Shift Hours:0800-1630
Job Type:Full-time
On-Call Required:No
Rotating Weekends:No
Rotating Holidays:No

Description

POSITION SUMMARY: Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Other payers). Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION REQUIRED: RN; BSN preferred

SPECIALIZED TRAINING REQUIRED: As required for RN licensure

LICENSE/CERTIFICATION/REGISTRATIONS REQUIRED: Licensed as a Registered Nurse in WA state; WA State Driver's License.

CONTINUING EDUCATION & COMPETENCY REQUIREMENTS:

Continuing education and/or licensing requirements:

As required for RN licensure

EXPERIENCE REQUIRED: Five (5) years recent clinical experience in a hospital setting, or four (4) years recent clinical experience and two years ICD-9 Coding experience. Utilization Review or coding experience preferred.

KNOWLEDGE/SKILLS/ABILITIES:

Requires excellent observation skills, analytical thinking, problem solving, and good verbal and written communication skills.

Professional demeanor, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside of the medical center. Contacts may be in person, by telephone, or through correspondence.

Critical thinking skills, able to assess, evaluate, and teach. Flexible with a working knowledge of all areas of adult medicine.

Works well with physicians, patients, family members, and employees.

ENVIRONMENTAL / JOB CONDITIONS:

Exposure to Hazardous Chemicals or Substances and/or Infection:

Risk of exposure to infectious disease during all patient contacts.

Exposure to Bloodborne Pathogens:

Risk of exposure to infectious disease during all patient contacts.

Personal Protective Equipment Required: None.

ACCOUNTABILITIES AND ESSENTIAL JOB FUNCTIONS:

Conducts a thorough review of the medical record for accurate and complete documentation reflecting the severity of illness of services rendered to patients with a DRG based payor. Demonstrates an ability to focus on pertinent details affecting the DRG. Demonstrates ability to apply CDMP techniques to identify the initial DRG correctly.

Identifies appropriate risk factors independently in cases reviewed. Identifies clinical indicators of illness severity in cases reviewed. Identifies appropriate treatment modalities in cases reviewed. Complete and accurate worksheets are created on each case reviewed.

Able to complete 8-10 new cases per day. Able to complete follow up reviews of open cases within 2 business days of last review. Maintains a filing system that allows for quick access to cases.

Demonstrates willingness to discuss positive and negative feedback regarding queries/cases. Explains program to others i.e. peers/nursing via scheduled inservices/presentations. Participates as a member of the Clinical Documentation Task Force.

Maintains a documentation clarification rate of greater than 20%. Clarifications are based on appropriate clinical and treatment factors. Formulates clearly defined questions indicating risk factors, signs and symptoms and treatments.

Initiates dialogue with physicians promoting the Clinical Documentation Program. Clearly articulates program objectives/benefits to physicians. Responds appropriately to questions in a timely manner.

Receives agreement with documentation clarifications in > 75% of cases. Obtains physician response to clarifications within 2 business days. Resolves all clarifications prior to discharge or follows up promptly with physician if patient is discharged.

Demonstrates good knowledge and use of CDMP guide software, utilizes decision trees, Docu-Prompter and coding clinics. Able to complete worksheets and Trak cases correctly.

Assists with special projects as needed.

Performs other duties as assigned.

Must have regular, reliable, predictable attendance in performance of essential job functions.

During an emergency, disaster, or catastrophic event, which places life or property in jeopardy, employee may be assigned to any disaster service activity that promotes the protection of public health and safety. Assignment might require serving at a location, at times and/or under conditions that significantly differ from employee's normal work assignments. As an employee of Harrison Medical Center, employee may be directed to perform a role other than their regular job, by a superior or by law.