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Title

Clinical Documentation Improvement Specialist (569) 

Category Health Information Services - 7180  
Description

JOB SUMMARY:

  • Reviews concurrent and/or discharged physician documentation to assure completeness, accuracy and consistency to improve overall quality of clinical documentation, to ensure the patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy and to ensure the most appropriate reimbursement is achieved for the level of service rendered to all inpatients.
  • Provides continuous education to both the Medical Staff and Coding Staff.
  • Communicates with clinical staff when documentation needs further specificity.
  • Initiates queries as necessary based on evaluation of clinical information.
  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes.
  • Uses assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal and external customers.
  • Articulates the program to physicians and other health care professionals in order to educate and teach clinical documentation requirements for DRG reimbursement, pay for performance quality outcome measures, CMI, ROM and SOI. Encourages a spirit of cooperation among clinicians.
  • Participates in clinical validation reviews and assists supervisor in denial and appeals processes.
  • Attends and actively participates in Clinical Documentation Improvement meetings with physicians.
  • Contributes to a positive working environment and performs other duties as assigned.

QUALIFICATIONS:

JOB SPECIFIC CORE COMPETENCIES:

  • Aptitude for detail and accuracy.
  • Ability to work unsupervised.
  • Abstracts relevant clinical and demographic information from the medical record for specificity of coding and reimbursement purposes.
  • Provides continuous education to Medical and Coding Staff.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

  • Bachelor of Science in Nursing preferred.
  • A degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 3 years inpatient coding experience will be considered in lieu of an RN.
  • If hired as RHIA or RHIT without CCS, CCS will be expected within 12 months of hire.
    • Assigns ICD diagnosis and procedural codes in accordance with coding and reimbursement guidelines including, but not limited to, the following:
      • Identifies principal and secondary diagnoses and procedures based upon UHDDS standards.
      • Uses fifth digit and sequencing conventions.
      • Documentation is present to substantiate codes assigned.
    • Abstracts relevant clinical and demographic information from the medical record.
    • Maintains a control system to assure completeness of the indexing system; enters all corrections in response to system edits and internal controls.
    • Serves as a coding resource for Patient Financial Services.
    • Refers coding and system questions to the supervisor/Director in a timely manner for determination and guideline development.
    • Assists in abstracting and retrieval of data for selected studies requested by Quality.
    • Keeps current on coding guidelines, rules and regulations, and new codes.
    • Keeps current on Clinical Documentation Improvement standards and guidelines.
    • Other duties as assigned.

EXPECTED BEHAVIORS

  • Accuracy: Accurately codes all diagnoses and procedures measured by Coding Quality Audits: 97 percent of all records for which the employee is responsible must be coded accurately to maximize DRG/APC weight.
  • Productivity Level:
  • Laboratory/Radiology coding: 2 minutes/record;
  • Provider Office Visits: 2 minutes/record;
  • Wound Professional Accounts: 2 minutes/record;
  • Recurring Patient Visits: 3 minutes/record;
  • ED/Urgent Care coding: 5 minutes/record;
  • Wound Clinic Accounts: 5 minutes/record;
  • Recurring Oncology: 5 minutes/record;
  • Outpatient Surgery and Short Stay coding: 12 minutes/record;
  • Peripheral vascular coding: 20 minutes/record;
  • Non-CCS Inpatient coding: 20 minutes/record.
  • Productivity Calculation:
  • Laboratory/Radiology coding: 2 mins/record x__________ charts;
  • RCR coding: 3 mins/record x__________ charts;
  • ED/Wound Clinic coding: 5 mins/record x__________ charts;
  • Recurring Oncology: 5 mins/record x__________ charts;
  • SDC/INO: 12 min/record x__________ charts;
  • Inpatient: 20 min/record x __________ charts.
  • Using productivity levels above, calculate hours produced and divide by hours worked. 95 - 100 percent - 2; 80 - 94.99 percent - 1; <80 percent - 0; B.
  • Abstracted information and codes are accurately keyed into the computer abstracting system. 97-100 percent - 2; 90-96.99 percent - 1; <90 percent - 0.
  • Coded accounts are monitored to assure required fields for each patient type are consistent and complete.
  • Corrects appropriate coding and abstracting discrepancies.
  • Assists Patient Financial Services in clarification of coding vs. reimbursement issues.
  • Seeks assistance only after referring to own resources.
  • Keys abstracted information for selected studies whe
 
Position Requirements

LICENSURE/CREDENTIAL REQUIREMENTS: RN preferred. RHIT or RHIA with CCS.

ADDITIONAL EDUCATION AND EXPERIENCE REQUIREMENTS:

  • Certified Coding Specialist (CCS) required. If hired without CCS certification, must obtain within first 24 months of hire.
  • Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) accepted if CCS certified.
  • Working knowledge of the ICD-9 coding systems, medical terminology, anatomy and physiology.
  • Experience in computer operations.
  • A minimum of three (3) years hospital inpatient coding experience or equivalent.
  • Types accurately at least 30 WPM.
  • Mandatory Continuing Education: Customer Service, Fire and Safety, Corporate Compliance (including Confidentiality), Infection Control, and education required by regulatory, accreditation bodies, scope of practice, and/or Hancock Regional Hospital.
 
Full-Time/Part-Time Full-Time  
Shift -not applicable-  
Sign-On Bonus  
Exempt/Non-Exempt  
Position Clinical Documentation Improvement Specialist (569)  
Number of Openings 1  
Exempt/Non-Exempt Non-Exempt  
Open Date 5/24/2023  
Location Hancock Regional Hospital  
About the Organization YOUR HEALTH IS OUR LIFE

Hancock Health is an Indiana-based, full-service healthcare network serving Hancock County and the surrounding areas. Our health system includes Hancock Regional Hospital, Hancock Physician Network and more than 20 other healthcare facilities, such as wellness centers, women's clinics, family practices, and the Sue Ann Wortman Cancer Center.

A Caring Community Partner
Our goal at Hancock Health is simple: To give every person the personalized attention necessary for a happy, healthy life. Our mission, vision, and values embody this goal.

OUR MISSION
To be a Caring Community Partner by healing, improving health and wellness, alleviating suffering, and delivering acts of kindness one person at a time.

OUR VISION
To be nationally recognized for kindness in the delivery of excellent quality patient care, efficient and effective operations, the adoption of proven technologies, the creation of a positive workplace environment, and excellence in community service.

OUR VALUES
Exceptional | Honorable | Devoted | Reliable | Kind  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.  

This position is currently not accepting applications.

To search for an open position, please go to http://HancockRegionalHospital.appone.com



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