Division:Eskenazi Health

Sub-Division: Hospital

Req ID: 21024 

Schedule: Full Time 

Shift: Days 

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.

FLSA Status

Exempt

Job Role Summary

This position exists to support the Hospital Clinical Documentation Improvement team. This position will be responsible for performing various quality reviews, preparing, and providing feedback to management and CDI team members and other departments, and assisting in developing Standard Work for team members. This position provides day-to-day education and training to CDI staff. Proactively contributes to Eskenazi Health’s mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County; models Eskenazi Health values

*Must be located in Indiana ; hybrid opportunity*

Essential Functions and Responsibilities

• Participate as a management liaison/representative in entity-based staff meetings, MD and staff-focused formal presentations/discussions, daily team instruction, assignment and reinforcement of CDI goals and avenues of workflow, identification, and discovery of new opportunity and/or adapted direction until which time the manager is required/available to intercede/participate.
• Orient new CDS staff regarding quality chart review methods, compliant query composition, timely follow-up and discussion, and handling of queries from initial review through to close, as well as overall department expectations and workflow.
• Training includes but is not limited to audio conferences, journal reviews, case studies, and testing training sessions may involve coordination with other hospital operational areas such as Quality, Compliance, Case Management, and other Clinical areas. 
• Oversees the development and implementation of ongoing formal and informal education of physicians, mid-levels, nursing, and other qualified clinical staff.
• Formulates and submits letters of appeal; creates an effective appeal utilizing relevant and effective clinical documentation from the medical record supported by current industry clinical guidelines, evidence-based medicine, community and national medical management standards and protocols.
• Provides ongoing support and consultation to improve the overall quality of medical record documentation; serves as a clinical resource consultant to the HIM coding staff when coders require clinical decision making and clinical interpretation to determine appropriate code assignment. 
• Provides primary clinical input into the ongoing planning and development of the Clinical Documentation Management Program (COMP) to support and enhance multidisciplinary performance improvement initiatives; facilitates interaction with medical staff and HIM coding staff to provide collaborative link between departments to promote accurate and complete physician documentation.
• Maintains a strong knowledge of DRG methodology, Severity of Illness/ Risk of Mortality statistics and Coding Clinic guidelines. 
• Identify process improvement opportunities for CDI staff to ensure quality outcomes. Develop, implement, disseminate, and adhere to policy and procedures related to CDI activities. Participate in organizational initiatives relative to CDI technology to improve accuracy and compliance. Serve as subject matter expert on accurate and appropriate coding and documentation standards, guidelines, and 
regulatory requirements.
• Responsible to support CDI staff in achieving departmental goals, including but not limited to all disciplinary actions, kronos time keeping and other day-to-day operational needs (i.e. creating and monitoring work queues and/or establishing daily workloads or project plans).

Job Requirements

• Indiana licensed Registered Nurse (RN) required.
• Must be a Certified Clinical Documentation Specialist (CCDS).
• Two (2) years of relevant inpatient CDS experience and three (3) years of relevant supervisor, lead, or senior experience required.
• Five years of strong and varied clinical experience in an acute care setting required.
• Recent hospital experience, preferably ICU, CCU or strong Med/Surg preferred.
• Knowledge of CMS Regulations
• Proficient in PC use, Microsoft applications and working knowledge of hospital department computer systems.

Knowledge, Skills & Abilities

• Knowledge of and proficiency in, application of Joint Commission, CMS, and ISDH health information management standards and regulations
• Knowledge of and proficiency in medical terminology, anatomy, and physiology
• Knowledge of ICD-10 and CPT-4 coding systems, as well as inpatient DRG and observation APC classification and reimbursement systems
• Knowledge of computerized abstracting systems and encoders
• Knowledge of revenue cycle process
• Microsoft Excel skills to include the ability to create and build new worksheets, import data, sort data, and use basic formulas
• Microsoft Word skills to write policies, procedures, and correspondence
• Familiarity with information systems used at Eskenazi, including, but not be limited to: MIC, EPIC, and 3M 360 Encompass is preferred
• Excellent oral and written communication skills; ability to present information to groups of physicians/individuals
• Excellent customer service and organizational skills; detail- and task-oriented; effectively manages time and workload, and sets appropriate priorities
• Ability to work independently and follow through on required assignments
• Ability to work as an effective team member
• Medical record documentation audit experience preferred
• Thorough knowledge of where to locate needed information in the medical record
• Responsible for abiding by the coding standards approved by cooperating parties (American Health Information Management Association, Center for Medicare and Medicaid Services, American Hospital Association, American Medical Association and National Center for Health Statistics) when applying to coding regulations
• Responsible for notifying management of inappropriate or unethical coding practices performed in the department
• Ability to work independently and exercise professional judgment to meet daily operational demands
• Demonstrates team-oriented, professional conduct when resolving operational issues which cross operational units within HIM and/or across Eskenazi Health
• Ability to function and effectively respond in stressful environments and situations
• Ability to demonstrate flexibility in response to changing situations and/or workloads.
• Knowledge of Observation and Inpatient medical necessity
• Advanced problem-solving, analytical, and critical thinking skills
• Ability to work effectively with all levels of the organization, including physicians.
• Knowledge of pathophysiology and disease process
• Knowledge of clinical documentation management tools and techniques
• Strong positive attitude; competent interpersonal skills

Accredited by The Joint Commission and named as one of Indiana’s best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute , Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.