Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Analyst (CDA), will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. This position will actively participate in educating appropriate hospital and medical staff about ICD-10.
Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures
Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider
Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes
Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals policy
Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting
Conducts educational sessions with physicians and other health care team members on documentation requirements
Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program
Reviews clinical issues and identified query response concerns with physician advisors
Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation
Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10
Participates in department and facility Quality and Performance initiatives
Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics
Works in conjunction with the Director of Quality, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement
Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff
Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff
Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health
Collaborates, coordinates and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding
Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities
Attends meetings as required and participates on committees and teams as directed
Education and Training: Licensed Registered Nurse, RHIA, RHIT, CCS, Paramedic, LPN or combination thereof preferred. Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.
Experience: Minimum of 4 years’ experience in an acute adult in-patient clinical role for RNs, Paramedics and LPNs with demonstrated critical thinking skills or a minimum of two years’ experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner or completion within 36 months. Bachelor’s degree in nursing may be substituted for two years of the required work experience. Knowledge of concurrent coding and documentation improvement, preferred. Experience in development of reference based continuing educational programs using Adult Learning Principles. Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor.
Our Vision & MissionOur vision is to serve our communities’ evolving healthcare needs by cultivating a network of compassionate, dedicated professionals. We are committed to working together, using best practices, improving quality, and assuring an exceptional patient experience.The mission of SageWest Health Care is to make our communities healthier. In order to achieve this, we are committed to five core values:Delivering high-quality patient careOur highest priority is caring for people - the friends, family and neighbors whom we serve in our community.Creating excellent workplaces for our employeesWe are committed to providing an environment based on respect and one which encourages personal and profession growth.Supporting physiciansWe support our physicians' practices by providing an innovative facility, advanced technology, and a well trained, organized clinical staff.Providing community valueWe are a vital resource for our community and because we take pride in our community, we are actively involved in supporting local, civic, and charitable organizations.Ensuring fiscal responsibilityWe are fiscally responsible ensuring that we meet our capital needs and the expectations of our stakeholders.
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