Clinical Doc Spec PRN
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Job Summary:
The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The PRN CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. PRN CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.
Core Responsibilities and Essential Functions:
Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff.
a) Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation.
b) Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
c) Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
d) Submits documentation clarification queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
e) Ensures queries are compliant, grammatically correct, concise, and free of typographical errors.
f) Provides appropriate follow-up on all queries.
g) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist.
h) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
i) Maintains required daily/weekly/monthly metrics. Meets productivity standards.
j) Participates in required departmental meetings, conference calls and presentations.
k) Adheres to departmental Policies and Procedures.
l) Submits ideas to improve workflow and increase productivity/efficiency of his/her team to the CDI Leadership Team and performs any other duties as assigned.
Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintains knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
a) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.
b) Participates in assuring hospital compliance with Federal and State regulatory requirements.
c) Educates members of the patient care team, including medical staff, on documentation guidelines on an on-going basis
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital, and regulatory outcomes.
a) Reviews data and trends to identify additional areas of opportunity.
b) Provides input to core measure and other quality data initiatives regarding areas for investigation and education.
c) Identifies and participates in opportunities to improve documentation, Epic, and quality of care initiatives.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum Education:
• Asso
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Job Summary:
The PRN Clinical Documentation Specialist (CDS) has strong knowledge and skills in clinical and coding concepts to enhance the quality and precision of the clinical documentation in the patient record on a concurrent, and possibly prospective and/or retrospective basis, using team-based processes. The PRN CDS cooperates with physicians, other healthcare professionals and coding team to make sure that the medical record contains accurate and complete clinical information that reflects the appropriate utilization, clinical severity, outcomes, and quality for the level of service provided to all patients, as well as ensuring compliant payment for patient care services. PRN CDS must communicate and collaborate well with CDI Leadership to offer CDI support as and when required to help the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.
Core Responsibilities and Essential Functions:
Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and HIM coding staff.
a) Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation.
b) Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
c) Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
d) Submits documentation clarification queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population.
e) Ensures queries are compliant, grammatically correct, concise, and free of typographical errors.
f) Provides appropriate follow-up on all queries.
g) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist.
h) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
i) Maintains required daily/weekly/monthly metrics. Meets productivity standards.
j) Participates in required departmental meetings, conference calls and presentations.
k) Adheres to departmental Policies and Procedures.
l) Submits ideas to improve workflow and increase productivity/efficiency of his/her team to the CDI Leadership Team and performs any other duties as assigned.
Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintains knowledge base of current medical terminology, procedures, medications, and diseases to provide accurate patient record analysis.
a) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.
b) Participates in assuring hospital compliance with Federal and State regulatory requirements.
c) Educates members of the patient care team, including medical staff, on documentation guidelines on an on-going basis
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital, and regulatory outcomes.
a) Reviews data and trends to identify additional areas of opportunity.
b) Provides input to core measure and other quality data initiatives regarding areas for investigation and education.
c) Identifies and participates in opportunities to improve documentation, Epic, and quality of care initiatives.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum Education:
• Asso
Apply tot his job
Apply To this Job