Raleigh, North Carolina
Raleigh, North Carolina
Durham, North Carolina
Wilmington, Delaware
Wilmington, Delaware
O'Fallon, Missouri
Posted: 18-Jan-23
Location: Cameron, Texas
Salary: Open
Categories:
Internal Number: 22024628
JOB SUMMARY
Clinical Doc Improvement Specialist 1 performs patient record reviews concurrently and/or retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Creates queries to physicians when needed to clarify ambiguous or incomplete documentation. The Clinical Doc Improv Spec 1 should have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
ESSENTIAL FUNCTIONS OF THE ROLE
- Facilitates accurate and complete documentation of medical conditions and treatment in patient records.
- Performs review of record to determine complete, accurate documentation of patient condition and treatment. As appropriate, the working DRG is updated.
- Promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners.
- Proficiently query practitioners regarding missing, unclear, or conflicting health record documentation in an effort to obtain additional documentation within the health record as needed.
- Appropriately escalates provider non-responses or inappropriate responses for reconciliation.
- Collaborates with Health Information Management coders and or auditors to reconcile working versus final coded DRG.
- Collaborates with peers who work directly with physicians.
KEY SUCCESS FACTORS
- Able to determine complete, accurate and timely documentation of all conditions.
- Able to obtain missing, ambiguous or incomplete information from practitioners.
- Able to analyze and interpret data in order to improve documentation practices.
- Able to collaboratively work with interdisciplinary teams.
- Able to provide ongoing education and information to practitioners regarding documentation practices.
- Knowledge of ICD-10, Complications/Comorbid Conditions and how each determines the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality
- 4 years of nursing Acute Care, Quality, or Case Management or 4 years of inpatient coding.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - Associate's
- MAJOR - Nursing
- EXPERIENCE - 4 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Registered Nurse (RN)
