SHIFT:7:00 AM - 3:00 PM
The Clinical Documentation Specialist conducts concurrent and retrospective medical documentation reviews on inpatient medical records to identify clinical indicators to support appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The Specialist facilitates comprehensive medical record documentation to reflect clinical treatment, diagnoses and decisions from physicians to bridge gaps in clinical documentation which address patient care and regulatory compliance. Under supervision, the Specialist completes timely documentation reviews to assign principal diagnosis and pertinent secondary diagnoses for inpatients admitted emergently, urgently and electively and outpatient services for completeness. Audits external Centers for Medicare & Medicaid Services (CMS) Recovery Audit Tracker (RAC) Audit results.Performs monthly audits of all internal coders for accuracy.Using broad knowledge of quality record medical documentation and regulatory directives, the Specialist coordinates point of care and/or retrospective documentation improvement to address severity of illness and risk mortality; and, for further use with patient care, quality of care and performance measurement, and reimbursement.
This position is exempt from Career Service under the CCHHS Personnel Rules.
- Completes initial reviews of inpatient health records within 24-48 hours of admission and outpatient health records for a specified patient population to evaluate documentation to assign the principal diagnosis and pertinent secondary diagnoses for severity of illness and risk of mortality
- Queries physicians regarding missing, under, or conflicting health record documentation and obtains additional documentation within the health record when needed
- Conducts follow-up reviews of patients every 2-3 days to support documentation adequacy upon patient discharge, as necessary
- Follows Cook County Health & Hospitals System (CCHHS) Clinical Documentation Program Guidelines in carrying out position functions; works accurately within the hospital's designated clinical documentation system
- Educates physicians and key healthcare providers regarding clinical documentation Improvement and the need for accurate and complete documentation in the health record
- Demonstrates an understanding of medical necessity, severity of Illness, complications, comorbidities, risk of mortality, case mix, secondary diagnoses, and procedures, and is able to impart this knowledge to physicians and other members of the interdisciplinary healthcare team
- Collaborates with the physician advisor, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge
- Participates in the analysis, interpretation and trending of statistical data for specified patient populations to identify opportunities for clinical documentation and process Improvement
- Assists with preparation and presentation of clinical documentation monitoring and trending reports for review with physicians and hospital leadership
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues Identified through daily and retrospective documentation reviews and aggregate data analysis
- Facilitates change processes required to capture needed documentation, such as forms and screen design
- Partners with the coding professionals to ensure adequate coding understanding to support clinical documentation necessary to determine a working severity of illness
- Reviews and clarifies clinical issues In the health record With the coding professionals that would support accurate and specific diagnoses and procedural coding
- Assists in appeal process resulting from third-party reviews
- Performs other duties as assigned
Reports to the Health Information Coding Quality Manager
- Valid license as a Registered Professional Nurse in the State of IllinoisORa Registered Health Information Technician (RHIT)ORa Registered Health Information Administrator (RHIA).(Must provide proof at time of interview)
- Three (3) years of experience in acute care nursingoras a registered health information technicianoras a registered health information administratorORa combination of the three totaling three (3) years of experience.
- One (1) year of experience within the last five (5) years working in Clinical Documentation Improvement.
- One (1) year of experience working with Case Mix, ICD 10 coding, principal and secondary diagnoses, procedures, complications, comorbidities, severity and patient mortality risk.
- Current experience with federal, state, and other payers’ regulatory requirements and criteria including, but not limited to, Medicare and Medicaid.
- Prior experience working in a hospital or health care environment.
- Must be detail oriented for clinical documentation review.
- Must be familiar with electronic health record systems, i.e. Cerner or Siemens.
- Five (5) years of acute care nursing experience or as a registered health information administrator.
- Two (2) years of experience within in the last three (3) years working in Clinical Documentation Improvement.
- Two (2) years of experience working with Case Mix, ICD 10 coding, principal and secondary diagnoses, procedures, complications, comorbidities, severity and patient mortality risk.
- Two (2) years of experience with federal, state, and other payers’ regulatory requirements and criteria including, but not limited to, Medicare and Medicaid.
- Current experience with InterQual and/or Milliman Care guidelines.
- Certified Documentation Improvement Practitioner (CDIP), or Certified Clinical Documentation Specialist (CCDS).
- Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCSP), or Certified Professional Coder (CPC).
- Registered Health Information Administrator (RHIA).
KNOWLEDGE, SKILLS, ABILITIES AND OTHER CHARACTERISTICS
- Knowledge and application of AHIMA, and/or ACDIS Ethical Standards.
- Knowledge of, but not limited to, current CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; ICD-10-CM/PCS and AMA CPT coding guidelines and conventions.
When applying for employment with the Cook County Health &Hospitals System, preference is given to honorably discharged Veterans who haveserved in the Armed Forces of the United States for not less than 6 months of continuousservice.
To take advantage ofthis preference a Veteranmust:
- Meet the minimum qualifications for the position.
- Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, “Are you a Military Veteran?”
- Attach a copy of theirDD 214, DD 215 or NGB 22(Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11).Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable
A copy of avalidState ID Card or Driver’s Licensewhich identifies the holder of theID as a Veteran, may also be attached to theapplication at time offiling.
If items are not attached, you will not beeligible for Veteran Preference.
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS ORAPPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW
MUST MEET REQUIREDQUALIFICATIONS AT TIME OF APPLICATION
- Medical, Dental, and Vision Coverage
- Basic Term Life Insurance
- Pension Plan
- Deferred Compensation Program
- Paid Holidays, Vacation, and Sick Time
- You may also qualify for the Public Service Loan Forgiveness Program (PSLF)
*Degrees awarded outside the United Stateswith the exception of those awarded in one of the United States' territoriesand Canada must be credentialed by an approved U.S. credential evaluationservice belonging to the National Association of Credential Evaluation Services(NACES) or the Association of International Credential Evaluators (AICE).Original credentialing documents must be presented at time of interview.
*Pleasenote all offers of Employment are contingent upon the following conditions:satisfactory professional & employment references, healthcare and criminalbackground checks, appropriate licensure/certifications and the successfulcompletion of a physical and pre-employment drug screen.
COOK COUNTY HEALTH AND HOSPITALS SYSTEM IS ANEQUAL OPPORTUNITY EMPLOYER