Specialist – Clinical Documentation Integrity – Pediatrics: CORP – Health Information Mgmt
Specialist – Clinical Documentation Integrity – Pediatrics: CORP – Health Information Mgmt
About This Job
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Summary:
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation to ensure that the patient’s acuity of care and severity of illness are accurately reflected in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to ensure that clinical documentation is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Reviews electronic medical records to construct compliant provider documentation clarifications.
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Detailed responsibilities:
• Reviews inpatient electronic medical records and constructs compliant provider clarifications to ensure that patient documentation reflects appropriate severity of illness and risk of mortality.
• Assigns and updates appropriate working DRG, diagnoses and procedures during initial and continued stay record reviews. Collaborates with Quality Management and Population Health specialists to advise of Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and Bundled Payments for Care Improvement (BPCI) admit diagnoses/Diagnosis Related Groups (DRGs).
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient s chart.
• Provides ongoing, one-on-one, or group education related to documentation integrity and compliance to physicians, extenders, nursing, clinical dieticians, wound care specialists, physical therapists and other allied health professionals. Collaborates with Auditor, Clinical Documentation Integrity (CDI) Compliance for education topics for staff training.
• Works with Medical Director, HIM to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation.
• Collaborates with coding staff to review patient’s clinical presentation/disease process, coder posed provider clarifications, and seeks guidance related to coding guidelines and assigned DRG.
• Generates CDI reports to monitor expected provider clarification and response rates, impact on case mix index (CMI) and reimbursement as appropriate.
• Maintains strict adherence to patient confidentiality according to MHS standards and regulatory requirements.
• Performs all duties as requested.
Experience & Requirements
Working Conditions
About Memorial Support Services
Disclaimer
Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity.
Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law.
We are proud to offer Veteran’s Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program.
Employment is subject to post offer, pre-placement assessment, including drug testing.
If you need reasonable accommodation during the application process, please call 954-276-8340 (M-F, 8am-5pm) or email TalentAcquisitionCenter@mhs.net
Job Details
Job Category:
Information Tech
Facility:
Memorial Support Services
Department:
Memorial Support Services
Job ID:
39494
Location:
Miramar, FL
Work Shift:
FT DAYS
Shift Hours:
8:00-16:30
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