Description
Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures. Conducts data quality reviews and provides feedback to ensure accurate and consistent coding in accordance with hospital specific guidelines, official guidelines, and regulatory requirements. Participates in the development of translational tools used by the organization to bridge the gap between ICD-9 and ICD-10. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, coders, and case management.
Responsibilities
- Completes initial reviews of all inpatient records within 24-48 hours of admission to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate APR-DRG assignment, risk of mortality, and severity of illness, CC and MCC capture; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients every 2?3 days to support and assign a working or final APR-DRG assignment upon patient discharge.
- Queries physicians regarding missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record when needed. This can be done verbally, electronically, or in person as appropriate.
- Queries providers in an ethical manner to avoid potential fraud and/or compliance issues.
- Escalates unanswered queries as appropriate to the physician advisor and follows outlined escalation process to complete queries.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Utilizes strong critical thinking and clinical expertise to effectively communicate documentation opportunities with providers.
- Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
- Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
- Facilitates change processes required to capture needed documentation, such as forms redesign.
- Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final APR-DRG, severity of illness, and/or risk of mortality.
- Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate APR-DRG assignment, severity of illness, and/or risk of mortality.
- Understands NCH quality metrics and healthcare regulations are essential to provide guidance to other hospital departments regarding documentation requirements.
Qualifications
Skills
- Critical reasoning skills in clinical decision-making, problem solving, and ability to interpret medical record data.
- Flexible, positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff.
- Knowledge of computer-based applications including but not limited to Word, Excel, 3M encoder, EHR (Epic).
- Organizational skills.
- Excellent written communication skills.
Education and Experience
Required
- Bachelors Degree in Nursing with current RN license in the state of Ohio or MBBS designation.
- Minimum of 5 years experience in inpatient medical/surgical or critical care setting.
Desired
- 10 years recent experience in a Pediatric inpatient medical/surgical or critical care setting.
- Certification in health-related field or Clinical Documentation Improvement (RHIA, RHIT, CDIP).
- At least 2 years of experience as a CDI Specialist.
- HIM Coding experience.
- Competency in ICD-10 documentation requirements.
- CDIP credential.
- NICU, Cardiology, Hem/Onc experience.