Document Specialist Clinical Rn

Receive 17% Weekday Nights, 26% Weekend Nights and 15% Weekend Day shift differentials

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: HIM Clinical Documentation

FTE: 1.00
Full Time

Shift: Days

Position Summary:

Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication.

Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for providers on appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures.

No patient care assignment.

Detailed responsibilities:
REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG
CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
PROBLEM SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness
ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested
COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Inform Coding management of potential and/or actual problems
PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on
REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software
REPORT ANALYSIS - Through report analysis, review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g., physicians, committee, intra-departmental, etc.) Perform individual and group analysis of physicians and outcomes related to service line documentation issues
EDUCATION - Provide information and education necessary to physicians and ancillary staff not responding to "queries" for appropriate follow up and consequences thereof. Identify opportunities for physician education to improve medical record documentation for severity of illness on an…