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TITLE: Clinical Documentation Specialist
JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.
DEPARTMENT: Health Information Management
HOURS OF WORK: Days Monday - Friday.
RESPONSIBLE TO: Supervisor, Clinical Documentation Improvement
PREREQUISITES:
1. Current unrestricted WA State Registered Nurse license, required.
2. Bachelor's degree in Nursing, preferred.
3. Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
4. Pass a pre-hire Clinical Exam with a minimum score of 70%
5. Effective communication with Providers
QUALIFICATIONS:
1. Knowledge of hospital clinical practice standards for physicians and other health care providers.
2. Knowledge of ancillary service departments, quality control and safety standards.
3. Critical thinking, problem solving and deductive reasoning skills.
4. Familiarity with health care audit and research design.
5. Knowledge of Pathophysiology and Disease process.
6. Functional knowledge of DRG coding systems.
7. Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
8. Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
9. Meet productivity guidelines.
10. Ability to learn/develop the skills necessary to perform and meet goal standards
11. Organizational, analytical, writing, and interpersonal skills
12. Dependable, self-directed, and pleasant
13. Critical thinking, problem solving and deductive reasoning skills
14. Knowledge of Pathophysiology and Disease Process
15. Basic Computer skills - familiarity with Windows based software programs
16. Knowledge of regulatory environment
17. Understand and support documentation strategies (upon completion of training)
18. Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:
See Generic Job Description for Administrative Partner.
PERFORMANCE RESPONSIBILITIES:
A. Generic Job Functions: See Generic Job Description for Administrative Partner.
B. Essential Responsibilities and Competencies
1. Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
2. Accurate and timely record review.
3. Recognize opportunities for documentation improvement.
4. Initiates severity worksheet for inpatients.
5. Formulate clinically credible documentation clarifications.
6. Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
7. Effective and appropriate communication with physicians.
8. Timely follow up on all cases and resolution of those with clinical documentation clarifications.
9. Communicates with HIM staff and resolves discrepancies.
10. Accurate input of data for reconciliation of case.
11. Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
12. Identify any barriers to completion of documentation goals with appropriate interventions.
13. Review of regulations and coding guidelines through seminars, meetings, and materials.
14. In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
15. Maintains confidentiality of all accessible patient financial or medical records information.
16. Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.
17. Other duties as assigned to facilitate accurate, timely patient account management.
Date Created: 5/18
Grade: NC27
FLSA: E
Cost Center: 8490
Job Qualifications:
PREREQUISITES:
1. Current unrestricted WA State Registered Nurse license, required.
2. Bachelor's degree in Nursing, preferred.
3. Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
4. Pass a pre-hire Clinical Exam with a minimum score of 70%
5. Effective communication with Providers
QUALIFICATIONS:
1. Knowledge of hospital clinical practice standards for physicians and other health care providers.
2. Knowledge of ancillary service departments, quality control and safety standards.
3. Critical thinking, problem solving and deductive reasoning skills.
4. Familiarity with health care audit and research design.
5. Knowledge of Pathophysiology and Disease process.
6. Functional knowledge of DRG coding systems.
7. Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
8. Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
9. Meet productivity guidelines.
10. Ability to learn/develop the skills necessary to perform and meet goal standards
11. Organizational, analytical, writing, and interpersonal skills
12. Dependable, self-directed, and pleasant
13. Critical thinking, problem solving and deductive reasoning skills
14. Knowledge of Pathophysiology and Disease Process
15. Basic Computer skills - familiarity with Windows based software programs
16. Knowledge of regulatory environment
17. Understand and support documentation strategies (upon completion of training)
18. Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
Reporting to the Chief Operating Officer of PDI, the Director of Revenue Cycle Management (RCM) will provide integrated oversight and management of revenue cycle activities for assigned LifeBridge Health Partners (Partners) companies to achieve Service Level Agreements (SLAs). The Director is responsible in accordance with SLAs to establish, monitor and manage all functional areas of the intake, billing, and collection operations to support optimized billing and cash flow. The Director assists with overall business planning, strategy, budgeting, trend analysis, evaluation, and performance of the Partner’s revenue cycle outcomes to achieve KPI’s and SLA expectations. Consults, coordinates, and serves as a liaison with Partner Companies and LBH Revenue Cycle leadership to achieve all applicable goals.
Essential Functions:
Intake, Billing, AR Management: Directs the Intake, Billing, Collections and AR functions. Directs and manages teams responsible for these functions. Provides strategic leadership for assigned revenue cycle functions and resources to support effective operations. Establishes and implements intake, billing and collection processes to support achievement of SLEs and SLAs and efficient management of the revenue cycle processes affecting both unbilled and billed accounts receivable. Establishes and achieves KPI performance expectations, assesses variances, identifies, develops, and tracks corrective actions and reports outcomes for revenue cycle operations. Where work is done collaboratively with Partners leadership, actively participates in and facilitates the team planning to achieve SLAs, SLEs and KPIs results. Implements procedures to support the timely and accurate completion of intake, submission of claims to payers and timely and effective claims follow up according to SLEs, keeping in compliance with work standards for turnaround time staying within timely filing deadlines to avoid past-time filing denials and writeoffs. Implements procedures and processes for effective patient collections activities. Escalates issues, using data-informed approaches for informed decision-making to leadership regarding any barriers to SLA and SLE performance. Focus areas include: Payor contracting, EDI enrollment, insurance verification and benefit coverage, claim submission, claims follow up with emphasis on timely remittance receipt and posting of payment, denials with focus on avoidance, deposits, cash application issues, and any other issues affecting accounts receivable management. Establishes and monitors a program for adjustments, write-offs and refunds. Periodically and regularly reviews key transactions and specifically reviews and approves appropriateness of large balance transactions. • Mentors and coaches staff to optimize compliance with and achievement of LBH SPIRIT values and operations performance goals. Appropriately involves LBH HR resources to support achievement.
Operations Oversight: Provides operations oversight, technical support and guidance to Partners accounts based on SLA tier. Uses data -informed approaches to support smarter, more effective leadership decisions and achievement of best practice business outcomes. Provides direct or indirect services based on SLA Tier Agreements. Provides directly and/or advises on appropriate level of revenue cycle staffing needed to process referrals, claims and account inventories timely and accurately to maximize collections and achieve performance goals. Assesses and makes recommendations for labor needed for both current and outstanding work, distinguishing between temporary labor needs to resolve a surge of outstanding work and permanent work volume requirements. Assesses staffing is aligned with work volumes, identifies variances and recommends corrective actions. Identifies and measures vendor performance efficiency, KPI achievement and contract compliance. Develops and maintains collaborative effective informed communication and relationships with vendor contacts. Directs day-to-day operations and activities within assigned scope to achieve goals. Creates and maintains a tracking list of issues, actions, and problem-solving statuses. Monitors staff quality and productivity to ensure acceptable performance standards are maintained. Reviews results with associates preferably weekly and at least monthly. Mentors and coaches staff to optimize performance. Proactively maintains positive employee relations. Meets with the IS or technical teams of contracted vendors on a regular basis to discuss work requests, resolve issues, system changes and available features. Serves as a liaison between Partner, external vendors, and LBH leadership.
Fiscal Management: Monitors Partner Revenue Cycle performance and the RCM impact on Partner financial performance goals. Plans and coordinates intake, billing, and collection activities to ensure positive financial outcomes. Meets or exceeds KPI and budget expectations for assigned SLAs to support Financial Statement and Operating Cash Flow Margin performance. Indirectly influences outcomes when working in an SLA advisory capacity. Assesses and make recommendations for expenditures needed to achieve performance outcomes. Develops, implements monitors and complies with internal controls over accounts receivables and cash receipt functions. Stays abreast of local, state and federal payor and governmental regulations and monitors compliance. Ensures adherence to LBH corporate human resources, compliance and revenue cycle billing and collection policies and procedures. Acts as advisory or primary resource for Partner issues or concerns regarding PDI managed functions. Develops corrective actions and implements action plans to address financial and compliance concerns. Manages budget to ensure financial goals are met. Assists with budget preparation and monthly reporting of financial outcomes and KPIs. Prepares and distributes reports according to designated schedule. Meets with key stakeholders to review performance. Communicates with key stakeholders as often as needed.
Reporting & Analysis: Provides access to cohesive, consistent, high-quality data and analysis. Assesses availability and facilitates access to data, analysis, qualitative and narrative reports and dashboards concerning the activities and outcomes of revenue cycle functions, including both internally managed programs and external vendor performance. Ensures all activities are monitored and KPIs are reported on a regular basis. Convenes the appropriate stakeholders to intervene and decide on actions when indicators are not trending favorably.
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.
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
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
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
You will be responsible for:
What will you need?
$70,000 - $80,000
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