Clinical Documentation Improvement Specialist

Job Requirements

Requisition Number
R-23770

Facility
LOC
0001 - 55 Fogg Road
55 Fogg Road Weymouth, MA 02190

Department Name
SHS Revenue Integrity

Status
Full time

Budgeted Hours
40

Shift
Day (United States of America)

Under the general supervision of the Manager of Clinical Documentation, will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness.

The documentation specialist is on-site and available five (5) days a week.

Compensation Pay Range
$ - $

• Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness
• Produce worklists from Epic daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission
• Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet.
• Identifies need to clarify documentation in records and initiates assertive communication with physician or other care provider by using the most appropriate communication method for that individual - physician documentation request, face to face contact, phone call, etc.
• Inputs current DRG into Epic for all Medicare patients daily.
• Inputs and reconciles queries on excel datasheet daily.
• Provide information and education as necessary to physicians and other care providers specific to DAP.
• Present overview of program to new physicians and other care providers at orientation
• Follow up with new physicians who document in medical records in a one-to-one meeting
• Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests
• Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation.
• Continual medical staff education as a proactive measure.
• Maintains a collaborative working relationship with team and with the Health Information Management department staff.
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness
• Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness
• Share pertinent coding and DRG reference materials (e.g. coding clinics)
• Share pertinent clinical information (e.g. new drugs/treatments)
• Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action
• Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis
• Identifies trends or potential problems and assists in developing action plans to address.
• Track and provide regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.
• Participates in organizational surveys that evaluate staff perception of safety.
• Seeks and participates in educational opportunities to improve job skills and program.
• Demonstrates knowledge of organizational safety priorities and their…