Inpatient Documentation Specialist (FT) – McLeod Florence
- Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values.
- Responsible for improving the overall quality and completeness of clinical documentation, including but not limited to:
- DRG validation
- Present on Admission (POA)
- Clinical Validation
- Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Medicaid, and others).
- Promotes capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations.
- Ensures the accuracy and completeness of clinical information/documentation to reflect accurate quality and outcome scores for both physician and medical center.
- Educate providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code set.
- Responsible for performing medical record review related to the 72 hour rule.
- Utilizes and interprets data using the hospitals designated clinical documentation system to identify factors for course adjustment, to stay on target and achieve operational program goals (volume of queries, query response rate and other departmental metrics)
- Communicate with providers either through discussion or in writing (e.g. formal queries) regarding missing, unclear, or conflicting health record documentation and clarify the information as warranted.
- Facilitates improvement in coding professionals’ clinical knowledge through increased collaboration with the discipline.
- Aid in identification and proper classification of complication codes (patient safety indicators/hospital acquired conditions)
- Responsible for adherence to guidelines, ensuring compliant queries.
- Works collaboratively with physician advisor when direct follow up with physician is needed.
- Educates all members of the patient care team on an ongoing basis regarding complications, co-morbidities, SOI, ROM, case mix and the impact of procedures on the billed record.
- Three years of recent clinical experience
- The ability to lead interdisciplinary teams to achieve outcomes
- Employee must have effective interpersonal communication skills and utilization of critical thinking in timely decision-making.
- Utilization Review, coding or case management experience
- Minimum of an Associate Degree in Nursing from an accredited school or equivalent related degree in allied health field
- CCDS or CDIP certification required within 2 years of hire
Florence, SC, United States