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Responsible for preparing statistical reports, coding diseases and operations according to accepted classification systems and maintaining indices according to established policies and procedures.
D.O.E.
$120,000 - $150,000
What You Will Do: Manage the daily operations of the clinical documentation area.
Assumes responsibility and accountability for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for WRMC. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.
$80,000-$90,000
Responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG’s, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
$105,000 - $120,000
Responsible for the oversight of the JHH, JHBMC, HCGH, SBH, and SMH Clinical Documentation Excellence surgical service lines that will be comprised of over 15 Registered Nurses (RN) and/or Health Information Professionals. This role reports to the Clinical Documentation Excellence Director and works in collaboration with the Clinical Documentation Excellence Manager (Medical Service Lines) and CDE Educator. This role identifies opportunities to improve surgical clinical documentation quality thru process review, performance/quality, and productivity reporting, and works with VPMAs, Directors, and others to implement improved process and enhancements. The manager acts as a systems expert on matters related to physician clinical documentation, coding, and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the health system. Works in collaboration with finance and quality staff along with leadership team and system hospital staff to support workflow and requirements that meet reporting, coverage, and quality review requirements. Works in collaboration with Clinicians, Quality Improvement/Assurance, JHHS HIM Coding, EPIC, data teams, 3M support teams, etc.
PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA).RHIT/RHIA: Must possess clinical documentation certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or American Health Information Management Association (AHIMA) and be a Certified Coding Specialist (CCS).
6 years of experience in the field of quality improvement, medical record/health information administration, acute care, clinical documentation and/or coding preferred. 1 year of staff management experience required at minimum if past experience is complemented by experience in inpatient, outpatient, compliance, medical necessity, charge master coding quality improvement, or surgical clinical documentation improvement.
$120,000-$140,000
Summary: The Clinical Documentation Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of HealthCare and the commitment to Extraordinary Care for Every Generation. This nurse is responsible for concurrent review of the clinical documentation in the medical record to facilitate appropriate physician documentation to accurately reflect patient severity of illness, risk of mortality, and DRG assignment. This nurse is accountable for meeting case mix goals, which translate into financial targets, and severity of illness, risk of mortality, and quality indicator goals, which impact hospital and physician profiling.
Responsibilities: Demonstrates excellent customer service. Contributes to organization success targets for patient satisfaction by meeting the Case Coordinator Expectations for Customer Satisfaction. Contributes to organization success targets for net operating margin. Ensures the availability of accurate and timely information. In collaboration with the physician, identifies principal and secondary diagnoses and procedures, and assigns a working DRG. Identifies options and relative weights when more than one diagnosis may be assigned as principal. Performs a thorough chart review to identify complications and comorbid conditions. Conducts the initial concurrent review process for all selected admissions to initiate the tracking process and documents findings on the DRG worksheet.
Assists in the development and distribution of APR/DRG physician profiling reports. Develops tracking reports to demonstrate effectiveness of program, analyzes findings, develops and implements action plans. Prepares administrative reports for presentation to Executives. Maintains accountability for meeting goals. Analyzes data reports to identify deficiencies in own practice, and actively seeks education to improve. Collaborates with HIM coders in this process.
Other information: EDUCATION/EXPERIENCE Education/Licensure/Certification Required: RN with current license in State of Michigan. Bachelor’s degree or willingness to complete within three years. Would consider a foreign national with an MD degree and CCDS certification.
Experience preferred/required: Minimum of 5 years clinical experience in an acute care setting required. Case management, ICU, CCU, or Med Surg. experience strongly preferred
KNOWLEDGE/SKILLS/ABILITIES
Knowledge of care delivery documentation systems and related medical record documents. Knowledge of age-specific needs and the elements of disease process and related procedures. Excellent communication and critical thinking skills. Working knowledge of Medicare reimbursement and coding structures. Ability to work independently in a time oriented environment. May be exposed to all patient elements, e.g. blood borne pathogens, and to environmental hazards such as anesthetic gases or elements. Demonstrates good computer skills.
$75,000-$85,000
Description/Purpose of Position:Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
Minimum Qualifications Education: Associates or Bachelor’s Degree in Nursing or Health Information Management
Experience: Minimum of five (3) years of clinical experience in an acute care setting critical care, medical/surgical or Emergency Department nursing preferred. Or, minimum of five (3) years of coding experience in an acute care setting.
Technical Skills: Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment.
License/Certification: Current RN license in the State of Nevada, or licensed RHIT or RHIA with CCS credential.
Other: Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Working knowledge of inpatient admission criteria, Medicare reimbursement system and coding systems preferred, but not required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time oriented environment is essential.
$90,000-$110,000
Position Summary:Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.
Essential Functions:
-Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
-Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
-Review medical record concurrently for documentation not yet in the record but supported by clinical indicators.
-Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet.-Determines the appropriate principle diagnosis of the patient
.-Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.-Documents findings in workflow tools, noting all key information used in the tracking process.
-Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.-Uses appropriate querying tools (templates) to capture needed documentation.-Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.
-Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
-Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports.-Able to identify areas of focus through report analysis.-Maintains reasonably regular, punctual attendance consistent with policies, the ADA, FMLA and other federal, state and local standards.
-Maintains compliance with all policies and procedures.Other related functions:-Maintains established work production standards.
-Assumes the responsibility for professional growth and development.
-Ability to work independently in a time-oriented environment.Education/Training:
-Graduate from an approved school of nursing.Licensure/Certification:
-Must maintain current Registered Nurse (RN) license in the State of Florida.Experience:
Five (5) years acute care hospital experience required.-Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
-Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
-Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
$70,000 - $80,000
The RN Documentation Specialist II demonstrates expert knowledge of documentation principles and is responsible for improving the overall quality and completeness of clinical documentation.
Facilitates modifications to clinical documentation through interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that documentation accurately reflects each patient’s severity of illness.
Ensures accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes and educates all members of the patient care team on an ongoing basis.
Specific Responsibilities: Demonstrates expert knowledge of DRG payor issues, documentation requirements and strategies, as well as policies and procedures. Improves the overall quality and completeness of clinical documentation by performing initial and continued stay reviews using clinical documentation guidelines.
Participates in the identification of quality indicators (PSIs, HACs) Provides ongoing communication with coders, auditors, care managers, nurses, and/or physicians to assure that documentation reflects the care and services provided.
Documents actions in the CDI software (3M 360) and conducts follow-up reviews of clinical documentation Processes discharges by updating the appropriate 3M 360 screens to reflect any changes in status, conferring with physicians to finalize diagnoses and assisting HIM in resolving post discharge queries.
Serves as a resource and educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Facilitates problem solving, education, and discussion at CDI meetings and training sessions. and provides team and department support.
Qualifications: Illinois RN license BSN or MSN required. Minimum of 3-5 years clinical nursing experience preferred. Critical Care and/or ED experience preferred.
At least 1-2 years Clinical Document Specialist experience required. Certification in clinical documentation improvement required within 1 year. Ability to demonstrate expert Clinical Documentation Specialist and coding knowledge. Excellent interpersonal communication skills, ability to work collaboratively with all members of the health care team.
Ability to travel throughout the Medical Center and maintain multi-unit assignment. Computer skills and the willingness to learn CDI software is required.
$90,000 - $100,000
If you're interested in one of our open positions, start by applying here and attaching your resume.We are seeking an experienced nurse for our clinical documentation improvement program.
Clinical Documentation Specialists (CDSs) work collaboratively with physicians, nursing staff, clinical caregivers, and coding staff to assure accurate and complete documentation in the medical record.
Through concurrent chart reviews CDSs use compliant processes to support the appropriate severity of illness, expected risk of mortality, complexity of care for each individual patient, and other documentation that results in high quality performance and appropriate reimbursement.
CDSs provide on-going education to physicians both one on one, in groups, and by educational tools.
Clinical Documentation Specialists adhere to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service.
Qualifications
• Graduate from an accredited school of nursing required. Bachelor’s degree preferred.
• Three years related clinical experience in an acute care setting required. Experience interacting with physicians required. ICD-10 coding and DRG experience a plus.
• Requires current licensure as a Registered Nurse in the state of Washington.
Highlights of the CDI Program
• Amazing support from administration
• Flexible work schedule
• Engaged Physician Advisor
• Escalation process in place
Benefits
• Free public transportation pass
• Competitive compensation package
• Generous PTO
• Medical, dental, vision
• 2 part retirement plan including matching
• Long term disability
• Flex spending
• Extended illness banked hours
• Free parking
• Employee Assistance program
• Professional development
Just a few of our employee perks
• Cell phone plan discounts
• Discounted Mariners and Sounders tickets
• Computer discounts
• Discounted lift tickets
• Discounted movie tickets
• Discounted gym memberships
• Free Seattle Art Museum passes
$95,000 - $105,000 + Relocation Assistance
Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.
Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
Description/Purpose of Position: Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services.
The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.
Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
Minimum QualificationsEducation: Associates or Bachelor’s Degree in Nursing or Health Information Management
Experience: Minimum of five (5) years of clinical experience in an acute care setting critical care, medical/surgical or Emergency Department nursing preferred. Or, minimum of five (5) years of coding experience in an acute care setting.
Technical Skills: Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment.
License/Certification: Current RN license in the State of Nevada, or licensed RHIT or RHIA with CCS credential.
Other: Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
Working knowledge of inpatient admission criteria, Medicare reimbursement system and coding systems preferred, but not required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time oriented environment is essential.
$80,000 - $110,000
Facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding,
APR-DGR assignment, severity level and reimbursement. Obtains appropriate documentation through interactions with physicians and staff. Educates members of the patient care team on documentation guidelines.
COMPENTENCIES
Education: Requires either successful completion of a RN program, successful completion of an AMA approved Physician Assistant program or successful completion of the academic requirements, at the baccalaureate level (RHIA), of an HIM program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).Knowledge:
Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process, pharmacology.
Requires college-level knowledge of Medical Terminology.
Requires a complete and thorough understanding of the unique functions of each clinical area. Must be conversent in: ICD-9-CM, APRDRGs, DRGs Must be proficient with Microsoft Word, Excel, and Power Point.
Knowledge of Access, knowledge of other programming languages a plus. Requires in-depth knowledge of clinical coding processing and documentation standards, guidelines, policies and procedures.
Must be conversant in clinical documentation improvement. High level of proficiency in adult education and training Requires a thorough understanding of Hospital bylaws and Joint Commission standards related to departmental activities.
Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into all of the data base systems used for clinical documentation. Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.
Requires understanding of HSCRC and CMI impact on hospital budget.Skills: Strong interpersonal, communication (verbal, non-verbal, and listening) skills. Experience in developing and presenting education programs. An understanding of adult learning theory and instructional design. Competent computer skills including word processing, spreadsheets, presentation software.
Analytical skills.
Required Licensure Certification: RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact. PA:
Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA). RHIA: Must possess certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) or be a Certified Coding Specialist (CCS).
Work Experience: RN : Requires a minimum of 3 years registered nurse clinical experience in similarly complex acute care setting. Familiarity with utilization review, case management, nurse review activities or coding experience preferred. PA:
Requires a minimum of 3 years as a Physician’s Assistant in a similarly complex acute care setting. RHIA: Requires minimum 3 years of previous APR-DRG validation experience and 5 years of coding and clinical documentation experience with extensive clinical knowledge in an acute hospital environment.
$80,000 - $105,000
Description
Clinical Documentation Analysts improve overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management and medical records coding staff/compliance specialists, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality and conditions present on admission. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.
Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations.Maintains a system to identify admissions for chart reviewInitiates chart review within 48-72 hours of identification.Monitors the reviewed medical record every 48 hours to determine compliance to established documentation standards.Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication when practical.Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintains an ongoing record of the results of each chart review including responses to each interventionServes as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information.Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations.Compiles and provides timely entry to CDI database for statistical reporting.
BSN or PA (Physician’s Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required. Experience3 years of relevant experience Degrees, Licensures, CertificationsCurrent licensure as an RN, NP, PA or licensure in the specific medical field associated with a Doctorate degree.CCDS, CCS, or CDIP certification preferred.
Excellent support from AdministrationFully electronic medical record (EPIC)Collaborative and innovative environment
$70,000 - $85,000
EXPERIENCE AND EDUCATION5 years nursing experience in an acute care Hospital setting, preferred in critical care; and 3 years experience working in a Clinical Documentation Integrity program.
RN required; with BSN preferred; and with a (CCDS) Certified Clinical Documentation Specialist, or (CDIP) Certified Documentation Improvement Practitioner, or must attain CCDS or CDIP within 6 months in position. Current TX RN license; current CPR certification
RN, BSN; or RN with 6 years of clinical experience and UR experience; OR RN, CCM with 4 years experience in related field.
JOB DUTIES
1. Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation..
2. Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding.
3. Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge.
4. Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation.
5. Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the ‘gaps’ between clinical and coding language.
6. Maintains an expert level of knowledge of CDI related practice and performance.
$70,000 - $90,000 DOE
You will be responsible for:
What will you need?
$70,000 - $80,000
Senior Level individual would manage CDI engagements with heavy involvement and role in overall client interaction and satisfaction. Responsible for overall delivery, education and training, and client support. Responsible for defining and shaping the services for each client and for changing rules and regulations. Manage multiple engagements with strong project management skills. Assist in the marketing and sales of CDI services through client presentations and discussions. Must have deep understanding and knowledge of clinical documentation improvement services with prior training experience strongly preferred.
healthcare setting with focus on documentation improvement and relative issues is strongly preferred
Great benefit package and bonus incentives. Salary open based on individual with expected base salary range of $100K – $160K plus bonus incentives. Position requires at least 70% travel to client sites, sales meetings, and regional/national conferences.
$100,000 - $150,000
The Clinical Documentation Specialist will provide active, concurrent and retrospective review of provider documentation, query for clarification, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, the CDS will work with the physicians to ensure high quality documentation that supports accurate representation of the care provided to the patient as reflected through MS-DRG assignment, case mix index, severity of illness, risk of mortality, quality measures, physician profiling, hospital profiling and reimbursement rules.
The CDS exhibits a comprehensive knowledge of clinical documentation requirements, DRG assignment, clinical conditions or procedures, and understanding of coding concepts and guidelines. The CDS is also responsible for communicating and educating members of the patients care team regarding documentation guidelines; and collaborating with other stakeholders, including Quality; Enterprise Coding; and Integrity.
Work Schedule, Hours, FTE, Salary Range ****This position is subject to a collective bargaining agreement with the Oregon Nurses Association (ONA)****This is a full time (1.0 FTE) position. Schedule will be Monday through Friday from 8:00 AM to 4:30 PM with possible weekends. Salary is based on the ONA contract.
This position is located in downtown Portland. We are hiring 4 applicants for this position.Functions/Duties of Position The Clinical registered nurse (RN) provides compassionate, evidence-based, and efficient care to individuals, families, communities and patient populations.
The Clinical RN’s care delivery is consistent with the Oregon Nurse Practice Act, the ANA Scope and Standards of Practice, and the ANA Code of Ethics. The Clinical RN demonstrates the professional role obligations of scientist, leader, practitioner, and knowledge transferor [O’Rourke Model of the Professional Role™]. Professional accountability enriches the Clinical RN’s engagement as a leader in promoting an inter-professional culture of collaborative decision-making, innovation, life-long learning, and teamwork.
The Clinical Nurse exemplifies the principles of a Culture of Safety by committing to a Just Culture, a Reporting Culture, Learning Culture, and an Engaged Informed Culture.
Job Requirements
REQUIRED:· External applicants- BSN required; · Current OHSU employees-BSN preferred; · Training in Clinical Documentation Improvement through ACDIS or AHIMA; · Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire · Minimum of 3-5 years of experience in acute care nursing (RN); at least 1 year of experience in a Clinical Documentation Integrity program. · Excellent observation skills, analytical and critical thinking, problem solving with good verbal and written communication skills. · Knowledge of age specific needs and the elements of disease processes and related procedures for the targeted patient population.
· Clinical knowledge and understanding of pathology/physiology of disease processes.
· Strong understanding of reimbursement and coding methodologies and guidelines; MS-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay. · Strong understanding of medical terminology. · Ability to work independently in time sensitive environment.
· Ability to work as a part of a multidisciplinary team. · Ability to assess, evaluate and teach key concepts related to documentation improvement. · Time management and project Management skills.
· Proficiency in computer use and windows based applications. · Current unencumbered Oregon RN.
· Valid Basic Life Support (BLS) certification issued by American Heart Association; Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire.PREFERRED:2-3 years of experience in a Clinical Documentation Integrity program with experience in clinical quality, utilization management, case management, or related field. Additional Details
WORKING CONDITIONS:Flexible schedule – may include rotating weekendsEqual opportunity, affirmative action institution. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or protected veteran status. Applicants with disabilities can request reasonable accommodation by contacting the Affirmative Action and Equal Opportunity Department at 503-494-51
$80,000 - $100,000