DOCUMENTATION SPEC-SOC SERVICE

• Completes initial review of patient records within 24-48 hours of admission / CDS assignment for all selected admissions covering all financial types. Performs concurrent review process to promote documentation that accurately reflects the severity of patient’s illness and complies with coding and documentation guidelines.
• Evaluates documentation and obtains additional documentation as needed to support assignment of the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness.
• Conducts follow up record reviews of patients every 2-3 days (after initial review)
• Develops and maintains documentation query protocol and educates staff on processes as needed.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Initiates assertive yet tactful communication with physician or other care provider when documentation is unclear, using the most appropriate communication method: Documentation Query Note in the EHR, face to face contact, phone call, etc.
• Consults Assistant Manager of Clinical Documentation as needed to obtain direction, clarification, and support in order to promote complete and quality clinical documentation.
• Tracks responses and trends compliance with physician queries.
• Educates physicians, residents and key healthcare providers regarding clinical documentation improvement and the importance of accurate and complete documentation in the health record.
• Identifies trends in clinical documentation and/or potential problems and develops action plans as needed.
• Partners with coding professionals to ensure accurate and complete documentation in the health record to determine a final DRG, severity of illness, and/or risk of mortality.
• Reviews and clarifies clinical issues in the health record with the coding professionals in order to support an accurate DRG assignment, severity of illness, and/or risk of mortality.
• Serves as a resource person for coding professionals to assist with coding/clinical questions.
• Maintains collaborative relationships with HIM and Nursing professionals.
• Reads and reviews coding guidelines, Medicare updates, professional journals, etc. to maintain an up-to-date working knowledge of coding and reimbursement principles.
• Contacts Medical Staff, Assistant Manager of Clinical Documentation, and/or Coders to expedite queries and facilitate final billing.
• Assist in other Clinical Documentation Improvement processes as needed.
• Other duties as assigned.

Job Requirements

• Current Registered Nurse (RN) licensure in the State of Ohio.
• Graduate of an approved School of Nursing; BSN or college courses preferred or experience in Inpatient Coding with Advanced Certifications (CCS, RHIT).
• Minimum of two years of acute care clinical experience required.
• Critical Care experience preferred.
• Excellent communication skills, both written, and oral.
• Knowledge and understanding of coding principles helpful.
• Ability to manage multiple demands from a variety of constituents.
• Able to effectively analyze data and present meaningful results to Medical Staff, Finance, and Clinical Division.
• Able to function independently, with autonomy, displaying personal integrity, always maintaining confidentiality.
• Able to work with all departments / personnel in a cross-functional environment.
• Refined negotiating skills and the ability to deal with problem solving and conflict resolution.
• Computer skills helpful (Excel, Word, PowerPoint, Medipac).