The Clinical Care Transformation (CCT) Second Level Reviewer performs quality audits of inpatient admissions and outpatient encounters to validate coding assignment is in compliance with the official coding guidelines as supported by clinical documentation in health record. Validates abstracted data elements that are integral to appropriate payment methodology. The CCT Second Level Reviewer works in collaboration with CDI specialists, Coders, Quality Analysts, Uhealth Providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support UHealth initiatives. Adheres to departmental and organizational goals, objectives, standards of performance, policies, and procedures, continually ensuring quality documentation and regulatory compliance.
- Conducts high volume internal audits of hospital medical records for documentation and coding accuracy. Participates on special reviews or projects.
- Ensures accuracy, completeness, and quality of clinical information used for measuring and reporting physician and hospital outcomes.
- Assists with concurrent and retrospective USNWR case reviews, quality audits, and education as deemed necessary by CTT Leadership.
- Performs high-level, complex, timely secondary case reviews concurrently and retrospectively to identify potential gaps or opportunities to facilitate improved provider documentation.
- Completes quality reviews focused on Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e. AHRQ Patient Safety Indicators).
- Demonstrates proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG by providing information regarding clinical documentation opportunities, coding and DRG issues, as well as performance improvement methodologies.
- Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment in decision making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement, and regulatory requirements.
- Makes recommendation of refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment.
- Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team. Works independently; demonstrates effective time management and prioritization of tasks.
- Participates in meetings, including providing feedback and identifying trends and opportunities, presentations for educational opportunities, and any other needs identified by the CTT leaders. Assumes responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation.
- Participates in departmental and organization projects, task forces, and/or committees as needed. Complies with and ensures adherence to HIPAA and Code of Conduct policies.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
- Four (4) Year/Bachelor's Degree Desired; AA/AS; BA/BS in related field Desired.
Certification and Licensing:
- Prefer AHIMA approved ICD10CM/PCS trainer.
- Proficient in ICD9CM/PCS, ICD10CM/PCS , CPT4, and HCPCS coding conventions and guidelines, encoder and National and Local Coverage Determinations.
- Certifications (CCS, CIC, or CPC) preferred.
- At least five (5) years recent inpatient acute care facility experience required.
- Demonstrated extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, pathophysiology, and disease management/treatment required.
- Proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG required.
- At least one (1) year experience with mortality, PSI, HAC, or other quality-focused reviews required.
- Knowledge of Vizient, Premier, US News and World Report, CMS star rating or similar risk-adjustment methodologies highly preferred.
- Prior experience in an academic medical center (AMC) or large health system preferred.
- Proficiency with Microsoft Office (Excel, PowerPoint, Word, Outlook) required.
- Experience with 3M 360 Encompass preferred.
- Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
Knowledge, Skills, and Attitudes
- General knowledge of office procedures and operations.
- Skill in data entry with minimal errors.
- Ability to accurately prepare and maintain records, files, reports and correspondence.
- Ability to communicate effectively in both oral and written form.
- Ability to handle difficult and stressful situations with professional composure.
- Ability to maintain effective interpersonal relationships.
- Ability to understand and follow instructions.