Analyst, Clinical Documentation

Clinical Documentation Analyst

Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Analyst will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Reports To:

HIM Director

FLSA:
Non-Exempt

Minimum Education:

Bachelor's degree preferred.

Licenses:
Credentialed status with AHIMA as a Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) preferred.

Certifications:

None listed.

Minimum

Work Experience:

At least two years in coding, along with knowledge of concurrent coding and documentation improvement, is desired. Knowledge of computerized encoding, grouping and abstracting systems is preferred.

Essential Functions:

• Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.
• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
• Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.
• Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
• Conducts educational sessions with physicians and other health care team members on documentation requirements.
• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff.
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.

Non
- Essential Functions:

• Acts as a strong advocate of the CDI program while educating physician, clinical, and other staff on the importance of clinically accurate documentation and the capture of data through ICD-10 coding.
• Demonstrates understanding of the importance of non-leading queries and communications with providers.
• Conducts CDI on-boarding education of all new admitting physicians as part of the hospital's orientation program.
• Reviews clinical issues and identified query response concerns with physician champion/advisors.
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
• Works closely with case management, quality management, risk/compliance management, and medical staff to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff leadership and other health care disciplines to assure effective monitoring and successful completion of identified plans for improvement.
• Safeguards the patient's right to privacy by judiciously protecting information of the patient and medical record as per HIPAA guidelines.
• Performs other duties as assigned.

EEOC Statement:

Centerpoint health – Georgetown is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.