Job Description

Department: HIM Clinical Documentation FTE: 1.00 Full Time Shift: Days Position Summary: Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for providers on appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment. Detailed responsibilities: REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate PROBLEM SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Inform Coding management of potential and/or actual problems PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software REPORT ANALYSIS - Through report analysis, review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g., physicians, committee, intra-departmental, etc.) Perform individual and group analysis of physicians and outcomes related to service line documentation issues EDUCATION - Provide information and education necessary to physicians and ancillary staff not responding to “queries” for appropriate follow up and consequences thereof. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coding for severity of illness and morbidity CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines OTHER - Perform other duties as assigned COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness and risk of mortality Qualifications Related Education and Experience may be substituted for one another on a year for year basis. Education: Essential: Program Graduate Nonessential: Bachelor's Degree Education specialization: Essential: Nationally Accredited Nursing Graduate Nonessential: Nursing Experience: Essential: 1 year directly related experience Nonessential: Documentation improvement experience Credentials: Essential: RN in NM or as allowed by reciprocal agreement by NM Nonessential: Certified Coding Specialist Certified Doc Improvement Prac/Spec (CDIP or CDIS) Physical Conditions: Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible. Working conditions: Essential: Minor Hazard - physical risks, dirt, dust, fumes, noise May work rotating shifts, holidays and weekends Department: Registered Nurse

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