临床文档专员-III 住院部
Clinical Documentation Specialist-III Inpatient
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负责整个系统中服务线整合的战略管理。能够进行专注和二级审查。在最高期望水平上独立工作。根据分配的任务协助经理完成特定项目。
最低资格要求：
教育、认证和/或执照：
1. 以下任一认证：
- 美国健康信息管理协会（AHIMA）颁发的认证文档完整性从业者（CDIP）
- 临床文档完整性专业人员协会（ACDIS）颁发的认证临床文档专家（CCDS）
- 美国专业编码员协会（AAPC）颁发的住院认证文档专家（CDEI）
经验：
1. 三年住院急性护理编码经验 或
三年住院急性护理临床护士（RN）经验 或
三年住院急性护理临床护师（LPN）经验。
2. 五年临床文档完整性经验。
核心职责和责任：此处描述的陈述旨在描述分配到此职位的人员所执行工作的总体性质。它们不打算被解释为所有职责和义务的详尽列表。可能分配其他职责。
1. 协助CDI经理进行高质量CDI部门的规划、执行和交付。
2. 协助CDI经理设计、收集和报告相关数据，以支持系统CDI计划。
3. 与CDI教育者/经理合作，提供医生的教育机会。
4. 作为CDI系统服务线专家，负责服务线的整合和战略管理，确保服务线团队专注于CDI的最大影响。
5. 参加与其指定系统服务线相关的所有收入完整性会议。
6. 能够高效地进行聚焦DRG和二级审查，并及时提供结果。
7. 与医生和员工合作，识别并记录主要诊断、次要诊断、手术，并分配一个工作诊断相关组（DRG）。
8. 对所有选定入院病例进行初始同时审查和持续复查。
查看英文原文
Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.
Responsible for strategic management of service line integration throughout the system. Capable of focused and second level reviews. Performs independently at the highest level of expectation. Assists Manager on specific projects as assigned.MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Certification in ONE of the Following:
- Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association (AHIMA)
- Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialists (ACDIS)
- Certified Documentation Expert Inpatient (CDEI) through the American Association of Professional Coders (AAPC)
EXPERIENCE:
1. Three (3) years Inpatient acute care coding experience OR
Three (3) years clinical RN experience in Inpatient acute care setting OR
Three (3) of clinical LPN experience in Inpatient acute care setting.
2. Five (5) years of experience in Clinical Documentation Integrity.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Assists CDI Manager in the planning, execution, and delivery of a high-quality CDI department.
2. Assists CDI Manager in the design, collection, and reporting of relevant data to support the System CDI Program.
3. Collaborates with CDI Educator/Manager for provider educational opportunities.
4. As a CDI system service line expert, responsible for integration and strategic management of service line, keeping the service line team focused on CDI greatest impact.
5. Attends all revenue integrity meetings related to their designated system service line.
6. Capable of efficient review and timely results for focused DRGs and second level reviews.
7. In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).
8. Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.
9. Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
10. Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries
11. Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.
12. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Report results assessment and improvement processes to the appropriate administrative levels.
13. Collaborate with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.
14. Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.
15. Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.
16. Serves as a mentor and advises Level I and II CDI Specialists.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Must be able to sit for long periods of time.
2. Must have visual and hearing acuity within the normal range.
3. Must have manual dexterity needed to operate computer and office equipment.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
2. May be exposed to standard patient care environment.
3. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.
4. May require travel.
SKILLS AND ABILITIES:
1. Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively.
2. Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.
3. Must possess the ability to accept mentoring, education and training from others.
4. Must meet quality and productivity standards.
5. Must be able to concentrate and maintain accuracy during constant interruptions.
6. Must possess the ability to prioritize job duties.
7. Must be able to adapt to changes in the workplace and work assignments.
8. Must possess organizational and time management skills.
9. Must possess the knowledge of anatomy, physiology and medical terminology.
10. Must possess analytical and problem-solving skills.
11. Must be proficient in office software programs.
12. Must be able to work independently with minimal supervision.
Additional Job Description:
Remote
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Exempt)Company:
SYSTEM West Virginia University Health SystemCost Center:
538 SYSTEM HIM CDIOriginally posted on Himalayas