Clinical Documentation Specialist, GA

JR-54919 How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives. Work Shift Various (United States of America) The Remote Clinical Documentation Specialist (CDS) demonstrates strong clinical knowledge and understanding of coding/DRG requirements to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The CDS works collaboratively with physicians, other healthcare professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services. Core Responsibilities and Essential Functions: Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, mid-level providers, case management team, nursing team, other patient caregivers, and HIM coding team. - Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation. - Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart. - Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned. - Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population. - Ensure queries are compliant, grammatically correct, concise and free of typographical errors. - Provides appropriate follow up on all queries. - Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist. - Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated. - Maintains required daily/weekly/monthly metrics. Meets productivity standards. - Participates in required onsite meetings, conference calls and Skype presentations. - Adheres to departmental Policies and Procedures. - Participates in assuring hospital compliance with Federal and State regulatory requirements. - Submit ideas to improve work flow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintain knowledge base of current medical terminology, procedures, medications and diseases to provide accurate patient record analysis. - Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes. - Reviews data and trends to identify additional areas of opportunity. - Provides input to core measure and other quality data initiatives regarding areas for investigation and education (PSI’s and HAC’s). - Identify and participate in opportunities to improve documentation, EPIC, and quality of care initiatives. Required Minimum Education: Bachelor's Degree in nursing or other health-related field Preferred Required Minimum License(s) and Certification(s): Cert Clin Document Specialist 1.00 Required Cert Coding Spec 1.00 Required Cert Document Improvement Prac 1.00 Required Reg Nurse (Single State) 1.00 Required RN - Multi-state Compact 1.00 Required Additional Licenses and Certifications: For candidates with a non-clinical background: at least one of the following active/current certifications is required:

• Certified Coding Specialist (CCS) from AHIMA
• Certified Professional Coder (CPC) from AAPC
• Registered Health Information Administrator (RHIA) from AHIMA
• Registered Health Information Technician (RHIT) from AHIMA

For candidates with nursing background, a current/active RN license is required. CCDS and/or CDIP certification preferred Required Minimum Experience:

• One or more years working in an acute care setting as a Clinical Documentation Specialist (CDS)- Required
• Minimum of five years of healthcare experience -Required

Preferred Experience:

• Prior experience of working as a CDI/Coding auditor is preferred
• Prior experience of working in inpatient case management or utilization review is preferred
• Strong medical surgical and/or critical care background Preferred
• Experience with care coordination/utilization management, coding/DRG, billing, auditing and various healthcare payers Preferred and
• Clinician preferred and/or CDIP/CCDS credential Preferred
• It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Required and
• EPIC Electronic Medical Record and CDI Software experience Preferred

Required Minimum Skills: Self-directed with good written communication skills necessary to effectively communicate with physicians and other healthcare providers. Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected. Chart review experience required. Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred. Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. Apply tot his job Apply To this Job