Clinical Documentation Integrity Specialist - HIM - FT - Days - MSS - Hybrid Eligible

Medical Documentation Specialist

Location: Miramar, Florida

At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.

Job Description

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.

Responsibilities

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). Works with Medical Director, HIM to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation. Maintains strict adherence to patient confidentiality according to MHS standards and regulatory requirements. Reviews inpatient electronic medical records and constructs compliant provider clarifications to ensure that patient documentation reflects appropriate severity of illness and risk of mortality. 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. Generates CDI reports to monitor expected provider clarification and response rates, impact on case mix index (CMI) and reimbursement as appropriate. Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient's chart. 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. Performs all duties as requested.

Competencies

ACCOUNTABILITY, ACCURACY - CDI, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, HEALTH INFORMATION MANAGEMENT (HIM) SYSTEMS - SPECIALISTS, HUMAN ANATOMY - CLINICAL DOC, MEDICAL CODING (CDI), MEDICAL TERMINOLOGY (2), PROBLEM SOLVING, PRODUCTIVITY - CDI, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR

Education and Certification Requirements

Accredited Program (Required)Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)

Working Conditions and Physical Requirements

• Bending and Stooping = 60%
• Climbing = 0%
• Keyboard Entry = 60%
• Kneeling = 40%
• Lifting/Carrying Patients 35 Pounds or Greater = 0%
• Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
• Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
• Lifting or Carrying > 75 lbs Non-Patient = 0%
• Pushing or Pulling 0 - 25 lbs Non-Patient = 60%
• Pushing or Pulling 26 - 75 lbs Non-Patient = 60%
• Pushing or Pulling > 75 lbs Non-Patient = 0%
• Reaching = 40%
• Repetitive Movement Foot/Leg = 40%
• Repetitive Movement Hand/Arm = 60%
• Running = 0%
• Sitting = 60%
• Squatting = 40%
• Standing = 60%
• Walking = 60%
• Audible Speech = 60%
• Hearing Acuity = 60%
• Smelling Acuity = 0%
• Taste Discrimination = 0%
• Depth Perception = 60%
• Distinguish Color = 60%
• Seeing - Far = 60%
• Seeing - Near = 60%
• Bio hazardous Waste = 0%
• Biological Hazards - Respiratory = 0%
• Biological Hazards - Skin or Ingestion = 0%
• Blood and/or Bodily Fluids = 0%
• Communicable Diseases and/or Pathogens = 40%
• Asbestos = 0%
• Cytotoxic Chemicals = 0%
• Dust = 40%
• Gas/Vapors/Fumes = 0%
• Hazardous Chemicals = 0%
• Hazardous Medication = 0%
• Latex = 0%
• Computer Monitor = 60%
• Domestic Animals = 40%
• Extreme Heat/Cold = 0%
• Fire Risk = 0%
• Hazardous Noise = 0%
• Heating Devices = 0%
• Hypoxia = 0%
• Laser/High Intensity Lights = 0%
• Magnetic Fields = 0%
• Moving Mechanical Parts = 0%
• Needles/Sharp Objects = 0%
• Potential Electric Shock = 0%
• Potential for Physical Assault = 0%
• Radiation = 0%
• Sudden Decompression During Flights = 0%
• Unprotected Heights = 0%
• Wet or Slippery Surfaces = 40%