CLINICAL DOCUMENTATION SPECIALIST - MEDICAL RECORDS ADMINISTRATION Job Number: 00121318
Job Posting: Feb 28, 2018, 7:24:29 PM Closing Date: Mar 31, 2018, 4:59:00 AM Full-time Shift Start Time: 7:00 A.M. Shift End Time: 3:00 P.M.
Posting Salary : Competitive
Organization: Health and Hospital Systems
The Clinical Documentation Specialist conducts concurrent and retrospective medical documentation reviews on inpatient medical records to identify clinical indicators to support appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The Specialist facilitates comprehensive medical record documentation to reflect clinical treatment, diagnoses and decisions from physicians to bridge gaps in clinical documentation which address patient care and regulatory compliance. Under supervision, the Specialist completes timely documentation reviews to assign principal diagnosis and pertinent secondary diagnoses for inpatients admitted emergently, urgently and electively and outpatient services for completeness. Audits external Centers for Medicare & Medicaid Services (CMS) Recovery Audit Tracker (RAC) Audit results. Performs monthly audits of all internal coders for accuracy. Using broad knowledge of quality record medical documentation and regulatory directives, the Specialist coordinates point of care and/or retrospective documentation improvement to address severity of illness and risk mortality; and, for further use with patient care, quality of care and performance measurement, and reimbursement.
This position is exempt from Career Service under the CCHHS Personnel Rules.
Completes initial reviews of inpatient health records within 24-48 hours of admission and outpatient health records for a specified patient population to evaluate documentation to assign the principal diagnosis and pertinent secondary diagnoses for severity of illness and risk of mortality
Queries physicians regarding missing, under, or conflicting health record documentation and obtains additional documentation within the health record when needed
Conducts follow-up reviews of patients every 2-3 days to support documentation adequacy upon patient discharge, as necessary
Follows Cook County Health & Hospitals System (CCHHS) Clinical Documentation Program Guidelines in carrying out position functions; works accurately within the hospital's designated clinical documentation system
Educates physicians and key healthcare providers regarding clinical documentation Improvement and the need for accurate and complete documentation in the health record
Demonstrates an understanding of medical necessity, severity of Illness, complications, comorbidities, risk of mortality, case mix, secondary diagnoses, and procedures, and is able to impart this knowledge to physicians and other members of the interdisciplinary healthcare team
Collaborates with the physician advisor, 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, interpretation and trending of statistical data for specified patient populations to identify opportunities for clinical documentation and process Improvement
Assists with preparation and presentation of clinical documentation monitoring and 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 and screen design
Partners with the coding professionals to ensure adequate coding understanding to support clinical documentation necessary to determine a working severity of illness
Reviews and clarifies clinical issues In the health record With the coding professionals that would support accurate and specific diagnoses and procedural coding
Assists in appeal process resulting from third-party reviews
Performs other duties as assigned
Reports to the Health Information Coding Quality Manager
Valid license as a Registered Professional Nurse in the State of Illinois OR a Registered Health Information Technician (RHIT). (Must provide proof at time of interview.)
Three (3) years of acute care nursing experience or as a registered health information technician
One (1) year of experience within the last five (5) years working in Clinical Documentation Improvement
One (1) year of experience working with Case Mix, ICD 10 coding, principal and secondary diagnoses, procedures, complications, comorbidities, severity and patient mortality risk
Current experience with federal, state, and other payers' regulatory requirements and criteria including, but not limited to, Medicare and Medicaid
Current experience with InterQual and/or Milliman Care guidelines
Prior experience working in a hospital or health care environment
Must be detail oriented for clinical documentation review
Must be familiar with electronic health record systems, i.e. Cerner or Siemens
Five (5) years of acute care nursing experience or as a registered health information administrator
Two (2) years of experience within in the last three (3) years working in Clinical Documentation Improvement
Two (2) years of experience working with Case Mix, ICD 10 coding, principal and secondary diagnoses, procedures, complications, comorbidities, severity and patient mortality risk
Two (2) years of experience with federal, state, and other payers' regulatory requirements and criteria including, but not limited to, Medicare and Medicaid
Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCSP), or Certified Professional Coder (CPC)
Registered Health Information Administrator (RHIA)
Knowledge, Skills, Abilities and Other Characteristics
Knowledge and application of AHIMA, and/or ACDIS Ethical Standards
Knowledge of, but not limited to, current CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; ICD-10-CM/PCS and AMA CPT coding guidelines and conventions
Interpersonal, verbal, written communication skills in dealing with inter and intradepartmental activities
Critical thinking skills with the ability to assess, evaluate, and teach
Organizational and analytical thinking skills
Ability to develop and maintain supportive, collaborative relationships with Physicians and other clinical professional
Ability to provide concise reports of activities and results.
Ability to work independently in performing duties with minimal supervision with a high degree of self-motivation
Ability to teach in a large group setting to educate healthcare providers about current documentation standards
Ability to track activities and communication across multiple physician services and forums
Ability to work with clinical manager, case management, and physicians to make clinical documentation improvements, i.e. change clinical documentation processes
Ability to analyze problems and issues and understand the regulatory and reimbursement impact of those decisions
Ability to become adaptable and self-motivated by staying abreast of CMS rules and regulations and incorporating those changes into daily practice
Proficiency in Microsoft Office Suite (Word, Excel, and PowerPoint)
When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service.
To take advantage of this preference a Veteran must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question,
The Cook County Health & Hospitals System’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCHHS is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCHHS is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, collaborative health plan and enhancing the patient experience.