门诊临床文档完整性专员 - CFH
Ambulatory Clin Doc Integrity Spec - CFH
概述
执行门诊病历审查,根据病历中的记录确定适当的编码分配,以支持提供的临床护理,包括预防性服务、 Medicare年度健康检查、最低和最高CPT E/M级别、新患者就诊与会诊的区别以及医疗必要性。通过为提供者和编码团队成员提供准确且及时的审计和编码教育,协助Carle内部高效且有效的临床编码服务,包括CPT E/M编码、CPT程序编码和ICD10CM编码,视情况而定。门诊CDI与HIM领导和合规部门紧密合作,确保Carle的提供者和编码团队成员遵循所有编码分配的监管要求。门诊CDI通过持续的内部提供者和员工审计来识别培训需求,并在教育后协助进行补救和重新审计。门诊CDI负责以提示、PowerPoint或一对一会议和小组教育会议等形式制作编码教育材料。在EMR中向医生发送通知和查询。
职责
· 重点改进文档,审查诊断和E/M代码的质量和完整性。
· 运用对医学术语、解剖学和生理学、疾病过程、治疗方式、诊断测试、药物和程序的全面知识,以确保正确的编码分配。
· 遵守公认的编码实践、指南和惯例以及任何相关的医院或医疗团队政策和指南。
· 协助设施员工满足文档要求,完整准确地反映所提供的患者护理。
· 向Carle医疗人员和HIM编码团队成员定期提供针对ICD10CM、CPT E/M或CPT手术编码的具体编码审查和反馈。
· 为编码团队成员和提供者提供与编码相关的教育和教育材料。
· 遵循查询和通知流程,必要时进行升级。
· 定期向经理/总监提供有关更改和删除编码的统计数据。
· 按照审计政策/实践的要求将结果升级至合规部门。
· 如有需要或指示,直接向HIM主任/副总裁报告合规或其他问题。
资格
认证:认证编码专家(CCS)- 美国健康信息管理协会(AHIMA)
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Overview
Performs ambulatory chart review to determine appropriate code assignment based on documentation in the chart to support clinical care provided, including preventives, Medicare Annual Wellness Visits, lowest and highest CPT E/M level, New Patient visits versus Consultation, and medical necessity. Assists in the provision of an efficient and effective clinical coding service within Carle by providing accurate and timely auditing and coding education to providers and coding team members to include CPT E/M coding, CPT Procedural Coding, and ICD10CM coding, as applicable. Ambulatory CDI work closely with HIM leadership and Compliance to assure Carle providers and coding team members are following all regulatory requirements for code assignment. Ambulatory CDI helps identify training needs through ongoing internal provider and staff audits and assists with remediation and reaudit post education. Ambulatory CDIs are responsible for producing coding education materials in formats such as Tips, power point or one to one sessions and group education sessions. Sends out notifications and queries to physicians in the EMR.Responsibilities
· Review quality and completeness of diagnostic and E/M codes with an emphasis on improving documentation.
· Apply comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code assignment.
· Adhere to accepted coding practices, guidelines, and conventions and any pertinent hospital or medical staff policies and guidelines.
· Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
· Provide regular coding reviews and feedback to Carle medical staff and HIM coding team members specific to ICD10CM, CPT E/M or CPT Surgical coding.
· Provide education and education materials related to coding for the coding team members and providers.
· Follow query and notification process and escalates, as necessary.
· Provide statistics around changed and deleted codes to Manager/Director on a regular cadence.
•Escalate results to Compliance as required by audit policy/practice. •Report compliance or other concerns directly to HIM Director/Vice President HIM as needed or indicated.Qualifications
Certifications: Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Certified Professional Coder - Hospital (CPCH) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Outpatient Coder (COC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Coding Specialist - Physician-Based (CCS-P) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA),
Education: High School Diploma or G.E.D
Carle Health Company Overview
Find it here.
Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.
Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: .
Salary Range
The compensation range for this position is $26.03per hour - $43.47per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.Originally posted on Himalayas