Clinical Document Improvement Specialist

Remote Clinical Documentation Specialist

Works under the supervision of the Manager to provide support consultation compliance to evidence-based care and clinical documentation practices. Facilitates and drives improvements in the clinical performance initiatives and helps to maintain regulatory compliant documentation. Performance relies on general nursing/clinical knowledge including pathophysiology pharmacology regulatory requirements and ACDIS professional guidelines. Advanced communication and education to a broad audience including medical staff patients clinical departments in the form of specific chart reviews and broad presentation/education. Collaborates regarding clinical and coding knowledge with key stakeholders within the organization. Responsibilities include concurrent review of the clinical documentation to obtain the most accurate and complete physician documentation that appropriately supports the severity of illness risk of mortality and proper reimbursement.

Responsibilities:

• Conducts initial and concurrent reviews of clinical documentation for all selected admissions to initiate the tracking process and document findings.
• Abstracts data from concurrent and retrospective charts as well as computerized data systems using documentation coding and query guidelines.
• Completes admission coding for swing bed and acute rehab visits. Understands reimbursement methodologies and coding guidelines for swing bed and acute rehab.
• Assigns and updates ICD-10-CM/PCS codes and working DRG for encounters reviewing in a timely manner and documenting thoroughly in clinical documentation integrity system.
• Identifies need to clarify documentation in records and initiates communication with provider utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patients severity of illness.
• Utilizes monitoring tools to track the progress of the concurrent review program interprets tracking information and reports findings.
• Rounds with physicians in patient rooms identifying opportunities and providing education on clinical documentation. Provides information and education as necessary to physicians and ancillary staff. This includes participation on work teams.
• Completes second level review including mortality reviews.
• Monitors all coding and DRG changes as well as coding and query guidelines. Provide information to business/clinical partners as to the impact. Proactivity research documentation and coding guidelines to support the organization.
• Provides feedback to others regarding their documentation findings on contributions to the improvement activities. Acts as mentors to caregivers to improve compliance with standards and documentation requirements.
• Participates in staff training and departmental improvement activities and uses the results of the quality of care activities to initiate change in practice. Communicates with coders to ensure that the correct DRG is assigned to each case receives feedback as a means of continuous self-improvement.
• Collaborates with other members of the interdisciplinary team to achieve accurate documentation for coding (example: rounds with physicians attends team conference). Collaborates with physicians to writes appeal letters for clinical DRG change denials received from payers.
• Assumes responsibility for professional development by participating in workshops conferences and/or in-services and maintains appropriate records of participation.

Education:

• Associate's Degree - Nursing - Required
• Bachelor's Degree - Nursing - Preferred

Work Experience:

• 3 Years - Clinical experience in an ICU/Critical Care acute care setting. - Required
• 1 Year - Experience in clinical documentation integrity functions - Preferred

Licenses and Certifications:

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - State Licensure/Or Compact State Licensure in state depending upon designated work location - Required Upon Hire
• Certified Clinical Documentation Specialist (CCDS) - Required within 2 Years Or
• Certified Documentation Improvement Practitioner (CDIP) - Required within 2 Years

Travel Requirements:

• Must be able to travel between various system facilities and off-site locations as needed. - Required

About Us:

Mosaic Life Care is a health care system in northwest Missouri. With a vision of transforming community health by being a life-care innovator Mosaic places the holistic needs of patients first by providing the right care at the right time and place offering high value and quality health care. Mosaic has a wide array of benefits to meet each employees individual needs. Our benefits were designed by listening to people just like you. Mosaic also offers several perks with a focus on ensuring our employees feel valued including concierge services employee lounge wellness programs free covered parking free on-site and virtual health clinics and many more. When paired with compensation and recognition it is what continues to make us the employer of choice for employees at any stage of their journey.