What are the responsibilities and job description for the Clinical Documentation Integrity Specialist I position at Prisma Health?
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Job Summary
Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of provider documentation. This is accomplished by medical record review, query process, and reconciliation process. Responsible for assisting in maintaining a financially healthy, productive department, and promoting their own development with an emphasis on evidence-based practice education.
Accountabilities
Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation. (60%)
Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (25%)
Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)
Develop and maintain supportive, collaborative relationships with providers and health care team members to include education and follow up. (2%)
Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies. (1%)
Serve as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.) (1%)
Assign a working DRG for health care team discharge planning and CDI use. (1%)
Performs other duties as assigne
Supervisory / Management Responsibilities
This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
Associate degree - Nursing, Health Information Management, or related field
2 years - Adult medical / surgical / critical care / ER / PACU nursing coding or related field
In Lieu Of
In Lieu of the education and experience requirements noted above, the following combination of education, training and / or experience will be considered an equivalent substitution : MD / DO / PA / NP
Required Certifications, Registrations, Licenses
RN / RHIA / RHIT / CCS / CIC / Licensure in related field
Knowledge, Skills and Abilities
Computer skills, keyboarding.
Strong communication skills with ability to interact with providers and remain tactful.
General knowledge of IPPS, ICD10 Coding, MS-DRG / APR-DRG and HCPCS coding systems. Preferred
Work Shift
Day (United States of America)
Location
Corporate
Facility
7001 Corporate
Department
70017540 Clinical Documentation Integrity
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