Clinical Documentation Specialist - Providence St. Josepth Health
Providence St. Joseph Health is calling a Clinical Documentation Specialist. This position can be located anywhere within the PSJH System footprint.
We are seeking a Clinical Documentation Specialist to be responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers thru the query process and supporting them with feedback to accurately reflect the true clinical picture within the medical record. Provider feedback is conveyed through attending practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation as needed. In partnering with the coding team, the CDS will be an expert with ICD-10, MS-DRG and APR-DRG assignment.
The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient care givers documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate. An additional goal will be to spend face-to-face time with the providers and quickly help the providers understand their specific documentation trends as illustrated thru ICD-10 assignment. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, cranial thinking, ability to work independently while following CMS guidelines, organizational policies, and procedures.
In this position you will have the following responsibilities:
Complete initial medical records reviews of patient records within 24-48 hours of admission for assigned patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG or APR-DRG assignment; and (b) Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG or APR-DRG assignment upon patient discharge as needed.
Is a positive contributor in how documentation will affect the Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), accuracy of Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation.
Performs medical record reviews, to assign a working DRG and obtain appropriate clinical documentation through extensive review of CDI-related documentation areas; draft and submit compliance queries for follow up with providers; conduct follow up reviews of clinical documentation to ensure points of clarification with providers have been recorded in the patients’ medical record
Collaborates with quality department to improve documentation for quality reporting and report on trends associated with documentation to ensure continued improvement
Communicates with coders to identify root cause of CDI-Coder final DRG mismatch and resolve incongruence
Meets and exceeds established productivity guidelines as well as additional key performance indicators such as review rates, query rates, agreement rates, etc.
Validates documentation concepts necessary in ICD-10 documentation for the CDI team, clinical teams, and provider.
Follows queries thru to completion.
Assists in training department staff new to CDI.
Maintains flexibility in supporting multiple hospitals based on organizational need regardless of system variation.
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM coding. Attends mandatory coding seminars on annual basis (IPPS updates) for inpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education as assigned.
Follows established processes and utilizes the identified tools supportive of the CDS role without variation unless discussed with leadership team.
Able to breakdown raw information and undefined problems into specific workable components that in-turn clearly identifies the issues at hand. Makes logical conclusions, anticipates obstacles and considers different approaches that are relevant to the decision making process.
Identifies and acts upon opportunities. Motivates others during times of organizational stress, ambiguity, and change. Creates an environment that encourages prudent risk-taking, sharing of best practices, and alerting groups to alternative approaches.
Consistently displays awareness and sensitivity to the needs of internal and/or external clients. Proactively ensures these needs are met or exceeded.
Communicates ideas or positions in a persuasive manner that builds support, agreement, or commitment. Takes actions that directly or indirectly influence others to create buy-in, gain trust, and motivate actions in others or win concessions without damaging relationships.
Voluntarily takes the first steps to identify and address existing and potential obstacles, issues, and opportunities.
Innovation: Improves organizational performance though the application of original thinking to existing and emerging methods, processes, products and services. Employs sound judgment in determining how innovations will be deployed to produce return on investment.
Anticipates, identifies and defines problems. Seeks root causes. Develops and implements practical and timely soluti