NP Clinical Documentation Specialist - FT - Days - CI Docu Integ Care
: Job Details :

DHR Health - US:TX:Edinburg - DaysSummary:FLSA STATUS: ? Exempt ? Non-Exempt MISSION STATEMENT: Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time. VISION: Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence. POSITION SUMMARY: Clinical Documentation Specialist (CDS, works closely with the medical staff, nursing staff, and coding staff in support of excellence in patient information documented in the medical record. Primary purpose of this role is to ensure that all diagnoses, care, and treatment are documented in support of patient care and accurate DRG assignment. Improves coding specificity by education physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided. This includes medical necessity, capturing complications/comorbidities during the patient's stay. They are accountable for the concurrent review of medical records to track documentation supporting the severity of the illness and resources utilized. They will assist in the development of educational resources necessary to assure compliance with federal, state, and private rules and regulations on data collections, coding, and reimbursement. The CDS also provides a mechanism and guidelines to assure documentation of pertinent clinical findings in the medical record and clarifies ambiguous documentation by the physician. The CDS helps to meet the Medicare conditions of Participation requirement that medical records contain complete information/documentation regarding evaluations, interventions, care provided, services, care plans, discharge plans, and the patient's response to those activities the CDS also helps to meet the JCAHO standard IM6.10 which sates: the medical record contains sufficient information to identify the patient, support the diagnosis/condition, justify the care, treatment and services; document the course and results of care, treatment and services, and promote continuity of care among providers POSITION EDUCATION/ QUALIFICATIONS:

• Graduation from a program of nursing, BSN, preferred or graduate of Health Information Management RHIT, RHIA preferred
• Current state Registered Nurse license in Texas, Nurse Practitioner license in Texas or Certified Coding Specialist
• Certification in coding or clinical documentation preferred
• Good written and verbal communication skills required
• Some evening or weekend work will be required
• Bilingual - English/Spanish preferred
• Dependable and self-directed
• Critical thinking, problem solving and deductive reasoning skills
• Recent hospital experience preferably ICU, CCU, or Med/Surg
• Basic computer skills - familiarity with Windows based software programs
• Knowledge of regulatory environment
• Requires excellent interpersonal skills with families in crisis
• Knowledge of State, Federal, and JCAHO regulations.
• Current state Registered Nurse license in Texas, Nurse Practitioner license in Texas or Certified Coding Specialist
• Certification in coding or clinical documentation preferred
• Good written and verbal communication skills required
• Some evening or weekend work will be required
• Bilingual - English/Spanish preferred

JOB KNOWLEDGE/EXPERIENCE:

• Two (2) years of recent inpatient experience preferred
• Five (5) years coding experience in an acute care setting preferred
• Organizational, analytical, writing and interpersonal skills
• Dependable and self-directed
• Critical thinking, problem solving and deductive reasoning skills
• Recent hospital experience preferably ICU, CCU, or Med/Surg
• Basic computer skills - familiarity with Windows based software programs
• Knowledge of regulatory environment
• Requires excellent interpersonal skills with families in crisis
• Knowledge of State, Federal, and JCAHO regulations.

Responsibilities:POSITION RESPONSIBILITIES:

• Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
• Reviews all clinical documentation for improvement and/or quality opportunities.
• Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis
• Provide education to physicians and other clinicians on compliant documentation practices to support medical necessity, severity, reimbursement and continuity of patient care. Acts as an effective change agent and educator for physicians and allied health staff.
• Serves as a clinical resource to the coding staff when coders require clinical interpretation to determine appropriate code assignment.
• The Clinical Documentation Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The CDS will:
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.
• Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures
• Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
• Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
• Gather and analyze information pertinent to documentation findings and outcomes
• Supports development of templates, databases and other tools to support accurate documentation. Provides reports to manager as requested. Maintains a strong knowledge of DRG methodology, severity of illness/risk of mortality statistics, quality indicators and coding guidelines.
• Possesses strong understanding of the requirements for clinical coding and billing according to the rules for Medicare, Medicaid, and commercial health plans along with knowledge of the Utilization Management Committee approved or established medical necessity criteria,
• Serves as a resource for RN Case Managers and providers to assign the correct patient status and level of care and support the medical necessity of services. Strives to maintain positive outcomes that are attained by effective problem solving, effective teaching, learning methods and teamwork with physicians/providers, Physician Education Coordinator, RN Case Managers, Patient Financial Services, Coding, Billing, and other team members as appropriate.
• Other duties as assigned.

Other information:LINES OF REPSONSIBILITIES: (Chain-of-command)1. Director ? 2. Vice President CUSTOMER SERVICE: Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.AGE SPECIFIC:Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age. AMERICANS WITH DISABILITIES ACT: (ADA): A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.The following table provides physical requirements that will be associated with, but not limited to, this position: Light/moderate lifting up to 20 lbs, from the floor to shoulder height. YesKneelingYesMust be able to assist other employees with lifting more than 20 lbs.YesWalkingYesLight/moderate carrying up to 20 lbs.YesStanding/SquattingYesStraight pullingYesSittingYesPulling hand over handYesPushingYesRepeated bendingYesStooping/BendingYesReaching above shoulderYesClimbing StairsYesSimple graspingYesClimbing LaddersNoDual simultaneous graspingYesDepth Perceptions neededYesAbility to seeYesIdentify ColorsYesOperating office equipmentYesTwistingYesOperating mechanical equipmentYesCrawlingNoAbility to read and writeYesAbility to CountYesAbility to hear verbal communication without aidYesOperating Personal VehicleYesAbility to comprehend written/verbal communicationYesOther: Ability to deal with stressYesOSHA CategoryIIIB. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents. C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way. D. Aptitudes: HIGH 1 2 3 4 5 6 LOWIntelligence: General learning ability: The ability to catch on or understand instructions and underlying principles. Ability to reason and make judgments. 3 Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3Numerical: Ability to perform arithmetic operations quickly and accurately. 2Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to visualize objects or two or three dimensions, or to think visually of geometric forms. 2Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform. If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.Employee Signature: Date: Transfer/Hire Date Effective: .