Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is recorded. Identifies and reviews primary and secondary diagnosis and complications to ensure diagnosis documentation and capture through addendums may identify patients who need to be seen. Identify and review for POA (Present on Admission) documentation. Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient. Perform CDI QA reviews, both concurrent, prebill and retrospective
Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc) to ensure complete and accurate diagnosis capture and coding. Collaborates in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Communicates information effectively with medical center leaders. Works with Coding Review Manager to develop, implement and monitor departmental policies and procedures that support organizational goals, business objectives, regulatory needs and requirements. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to leaders, local regional management and medical team. Monitor and track verbal and written queries and produce reports as required.
Nursing/clinical 3-5 yrs experience, in patient, clinical documentation, discharge planning, or case management or case/utilization management. Knowledge of MS-DRGs and the payment methodology.
- Strong interpersonal, communication (verbal, non-verbal, and listening skills). Understand Adult Learning Theory.
- Competent computer skills including word processing, spreadsheets, and presentation software. Must have strong analytical skills.
- Understand coding classifications systems such as, but not limited to ICD-9 CM, MS-DRG, HCC strongly preferred.
- Demonstrated ability to conduct and interpret quantitative/qualitative analysis.
- Proven leadership skills in project management and consulting.
- Must exhibit efficiency, collaboration, candor, openness, and results orientation
- Seasoned coders with clinical knowledge and experience with over 10+ years may also qualify.
Peak Health Solutions, an AMN Healthcare company, is an EEO/AA/Disability/Protected Veteran Employer. We encourage minority and female applicants to apply
Clinical Documentation Specialist