Clinical Documentation Specialist - PRN - Days - Cl Docu Integ CareUS:TX:Edinburg | QUALITY & COMPLIANCE | PRNOur Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time. Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence. The role of Clinical Documentation Specialist of Clinical Documentation Improvement Department (CDI) works closely with the Director of CDI in addition to the other clinical documentation specialists, medical and coding staff in support of excellence in patient information documented in the medical record. Primary purpose of this role is to provide oversite of the medical record that ensures care, and treatments are documented in support of patient care and accurate DRG assignment. The goal being to accurately define coding and documentation specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided. The role of Clinical Documentation Specialist of CDI will ensure the specialists review thorough and proper documentation during the patient's stay. The Clinical Documentation Specialist of CDI will be accountable for the concurrent review of medical records to track documentation supporting the severity of the illness and resources utilized. This position will use existing clinical knowledge from previous training to impart the values of clinical documentation across the various DHR Health departments. This role will require utilize the candidate's previous clinical experience in a hospital setting to leverage knowledge of clinical medicine in regards to the proper documentation needed on a daily basis. The role will require both onsite and off-site completion of daily job requirements. This position may require travel to facilities (Cameron County and Starr County) outside the DHR main campus which is required to oversee operations of clinical documentation in facilities working in partnership with DHR.
POSITION EDUCATION/ QUALIFICATIONS:
Foreign Medical graduate (M.D)/ Doctor of Osteopathy (D.O), Registered Nurse (R.N) or similar. Proficiency in written and spoken EnglishCCS Exam certification or CCDS Exam certification after two years of employment but must be obtained no later than 2 ½ years after hire date. Able to meet the requirements for CCS Exam requirements either based on experience or education as detailed on the AHIMA or the CCDS Exam requirements as detailed on the ACDIS website. JOB KNOWLEDGE/EXPERIENCE:Minimum 1 year clinical experience in acute care setting Knowledge of EMR and related medical record documents, coding and documentation. Knowledge of disease process and pathology amongst various patient populations Knowledge of treatment modalities for disease process and pathologies Strong understanding of anatomy, pathology, pharmacology and physiology of disease process. Excellent written, verbal communication skills and critical thinking skills. Able to work with teams and independently.
Responsibilities
POSITION RESPONSIBILITIES:- Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.· Reviews all clinical documentation for improvement and/or quality opportunities.· Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis· Provide education to physicians and other clinicians on compliant documentation practices to support medical necessity, severity, reimbursement and continuity of patient care. Acts as an effective change agent and educator for physicians and allied health staff.· Serves as a clinical resource to the coding staff when coders require clinical interpretation to determine appropriate code assignment.· The Clinical Documentation Specialist facilitates clarification to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The Clinical Documentation Specialist will:· Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.· Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures· Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness· Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.· Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team· Gather and analyze information pertinent to documentation findings and outcomes.· Supports development of templates, databases and other tools to support accurate documentation. Provides reports to manager as requested. Maintains a strong knowledge of DRG methodology, severity of illness/risk of mortality statistics, and coding guidelines.· Possesses strong understanding of the requirements for clinical coding and billing according to the rules for Medicare, Medicaid, and commercial health plans.
Other information
LINES OF REPSONSIBILITIES: (Chain-of-command)
Manager?
2. Physician ExecutiveCUSTOMER SERVICE:Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service. AGE SPECIFIC:Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.
AMERICANS WITH DISABILITIES ACT: (ADA):A.
Essential Duties:
Indicated by bold print within performance standards, preceding individual numbered criteria. The following table provides physical requirements that will be associated with, but not limited to, this position: Light/moderate lifting up to 20 lbs, from the floor to shoulder height. - Yes - Kneeling - YesMust be able to assist other employees with lifting more than 20 lbs. - Yes - Walking - YesLight/moderate carrying up to 20 lbs. - Yes - Standing/Squatting - YesStraight pulling - Yes - Sitting - YesPulling hand over hand - Yes - Pushing - YesRepeated bending - Yes - Stooping/Bending - YesReaching above shoulder - Yes - Climbing Stairs - YesSimple grasping - Yes - Climbing Ladders - NoDual simultaneous grasping - Yes - Depth Perceptions needed - YesAbility to see - Yes - Identify Colors - YesOperating office equipment - Yes - Twisting - YesOperating mechanical equipment - Yes - Crawling - NoAbility to read and write - Yes - Ability to Count - YesAbility to hear verbal communication without aid - Yes - Operating Personal Vehicle - YesAbility to comprehend written/verbal communication - Yes - Other: Ability to deal with stress - YesOSHA Category - IIIB.
Working Conditions:
The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents. C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way. D. Aptitudes: HIGH 1 2 3 4 5 6 LOWIntelligence: General learning
