Clinical Documentation Reviewer

Hiring PRN Status

The PASC will assure the accurate extraction of data from the clinical documentation. To perform this task the PASC will:

• Use discretion and independent judgment

• Coordinate the process of providing accurate and timely data to the appropriate entities involved for Medicare patients.

• Oversees all aspects of data collection on the IRF-PAI.

• Ensures the presence of supporting documentation

• Work closely with CNO and DTO to ensure compliance with CMS guidelines

• Educate staff on proper and accurate documentation as it applies to the IRF PAI.

• Develops and interprets policies and procedures and acts as the primary resource for immediate problem solving in regards to FIM scoring and CARE coding.

This position requires a positive working relationship as well as serving as an educator to the medical staff.

Job Code: 101015

Qualifications

POSITION REQUIREMENTS AND ESSENTIAL JOB FUNCTIONS

License or Certification:

• Clinical licensed professional such as nurse, therapist, case management or other allied health provider

• FIM certified

Education, Training and Years of Experience:

• Appropriate to licensure , i.e., bachelors, associates degree or allied health degree as required for licensure

• 1 year experience in the healthcare setting

Machines, Equipment Used:

• General office equipment such as telephone, copy machine, fax machine, calculator, computer.

Physical Requirements:

• Good visual acuity and ability to communicate.

• Ability to lift, lower, push, pull, and retrieve objects weighing a minimum of 30 pounds including medical supplies and equipment and the transferring and repositioning of patients. Reasonable assistance may be requested when lifting, pushing, and/or pulling are undertaken which exceeds these minimum requirements.

Compliance:

• Adheres to the company's Standards of Business Conduct.

• Adheres to CMS and JC standards

• Maintains current licensure and/or certifications, if applicable.

Skills and Abilities:

• Ability to speak, read, write, and communicate effectively.

• Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner.

• Ability to work independently without constant supervision.

Environmental Conditions:

• Indoor, temperature controlled, smoke-free environment. Occasional outdoor exposure.

• Exposure or potential exposure to blood and body fluids may be required.

• Handicapped accessible.

• May work under stressful circumstances at times.

Proficiency or Productivity Standards:

• Has regular, reliable and predictable attendance and punctuality.

• Adheres to hospital/department dress code including wearing ID badge.

• May be required to work weekdays and/or weekends, evenings and or night shifts if needed to meet deadlines, monitor processes or educate staff.

• May be required to work on religious and/or legal holidays on scheduled days/shifts.

• Will be required to work as necessary during disaster situations, i.e., before, during or after a disaster.

• May be required to stay after workday to assist after a disaster situation until relief arrives.

• May be required to perform other duties as assigned by supervisor.