This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation. This position facilitates modifications to clinical documentation through concurrent interaction with physicians (verbally and electronically) and other members of the health care team. The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding.
Desired Skill Set
- Clinical Documentation experience highly preferred
- Prefer 5yrs clinical (bedside) RN experience in acute hospital setting
- Prefer ICU/IMU RN experience
Associate’s Degree in Nursing (ASN) or RHIT required. Bachelor's Degree in Nursing or RHIT preferred.
- Current RN licensure with five (5) years recent clinical experience in a hospital setting or
- Certified Coding Specialist (CCS) with at least two (2) years of inpatient coding experience and two (2) years of Clinical Documentation Specialist experience and
- Either a Certified Document Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS)
- All incumbents not certified with a CCDS upon hire must become certified within two (2) years of hire date
- Incumbents in the role as of 1/1/2011 are grandfathered into the role
Experience / Knowledge / Skills
- Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
- Possesses a working knowledge of many areas of adult medicine
- Able to assess, evaluate, and teach
- Proficiency in organization and planning
- Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
- Ability and willingness to seek out and accept change
- Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
- Knowledge of federal, state and private payer regulations preferred
- Professional, team player, able to communicate well with others
- Strong interpersonal skills and positive attitude
- Regular, significant contact with other personnel throughout and outside Memorial Hermann; Contact may be in person, by telephone, or through correspondence
- Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.
- Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
- Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes.
- Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
- 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 system.
- Gathers and analyzes information pertinent to documentation findings and outcomes.
- Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.
- Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
- Identifies patterns, trends variances and opportunities to improve documentation review and process.
- Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement.
- Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information.
- Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation.
- Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness.
- Documents conference and results.
- Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities.
- Complies with HIPAA and Code of Conduct policies.
- Assists with special projects as needed.
- Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation.
- Directors shall determine percentage weight distribution for each competency category.
- Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Other duties as assigned.