Clinical Documentation Improvement Specialist-Coder Job
Job Number: 00073-45205
Location: Plaza Medical Center of Fort Worth (Fort Worth, TX)
Position Responsibilities:
- Concurrent analysis of in patient records to establish applicable diagnosis
- Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis
- Educate Clinical and Medical Staff regarding documentation requirements specific to disease/diagnosis
Department Specific Criteria:
- Concurrently reviews selected admissions to identify most appropriate principal and secondary diagnosis to accurately reflect the patients severity of illness
- Communicates with physicians and clinicians regarding missing, unclear or conflicting medical record documentation to clarify and obtain needed documentation.
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Reviews medical records and identifies potential gaps in clinical documentation for specified patient types (e.g., I/P, O/P, etc.) and payer populations (e.g., Medicare, Medicaid, Blue Cross/Blue Shield, etc.) as directed on admission and throughout hospitalization.
- Develops clinician or physician education strategies to promote complete and accurate documentation and correct negative trends
- Confers with Coders concurrently to ensure appropriate DRG and completeness of supporting documentation
- Completes concurrent review on 85% of assigned population.
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Achieves and maintains 95% accuracy rate.
- Develops tools and coordinates audits for compliance
- Gathers and analyzes information pertinent to documentation findings and outcomes
- Identifies patterns and trends variance, identifying opportunities for improvement
- Researches literature to identify new methods in development for disease components and documentation
Qualifications:
- Either Current Texas Registered Nurse License
- RHIA, RHIT, CCS
- Bachelors Degree in Nursing or Healthcare related field preferred
- Undergraduate degree in Health Information Management or health care related field required
- Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) required.
- Experience in Quality, Case Mgm, Clinical Audit or Data Abstraction necessary
- Interpersonal Communication skills to motivate and manage an improvement process
- Minimum 5 years recent health information management, case management/utilization/quality review and/or other related clinical experience in an acute care facility required; 3 years acute care inpatient coding experience preferred.