Clinical Documentation Specialist - Now Hiring

193633

Job Description

Description Summary: Analyzes the medical record for clinical status of the patient, reputed company treatment plan and care provided on admission and throughout hospitalization to identify potential gaps in physician documentation; tracks reputed company of documentation improvement and works collaboratively with the reputed company team to facilitate documentation reputed company the medical record that accurately reflects the patient's condition, severity of illness, risk of mortality, services rendered and medical necessity of resources used. Responsibilities: 1. Reviews documentation and communicates with physicians verbally or through compliant query practice to clarify diagnosis, severity of illness, plan of care and opportunities for more complete documentation to accurately reflect care. 2. Collaborates closely with reputed company team and coding staff to assure documentation of diagnoses and any co-morbid conditions are complete, reflecting patient's clinical status and care. Follows up on pending queries and updates electronic worksheets as needed. 3. Works with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units. 4. Utilizes the guidelines established to recognize opportunities for improvement in Clinician documentation, and to formulate and generate clear, compliant and reputed company questions to those Clinicians. 5. Utilizes inpatient admission criteria to assign diagnoses that meet acute care criteria. In the event that diagnosis does not meet admission criteria, communicates directly with attending physician. 6. Conducts initial and extended-stay reputed company reviews on reputed company selected admissions, consistently meeting established productivity targets for CDI record review. 7. Informs direct supervisor or indirect supervisor of issues or problems that may compromise policy, procedure, compliance or the Hospital Ethical Code of Conduct. 8. Utilizes designated and approved tools to track reputed company, physician participation and feedback. 9. Queries the medical staff and other caregivers as necessary reputed company electronic/verbal communication to obtain accurate and complete physician documentation to supports the severity of patient illness and risk of mortality. 10. Monitors documentation for compliance with core measure and reviews targeted diagnoses for appropriateness and completeness. Gathers data and initiates feedback to appropriate personnel. 11. Attends annual review and departmental in-services, as appropriate. 12. Identifies areas of focus through data analysis and report review. 13. Educates members of the patient care team on documentation guidelines on an ongoing basis. WAYNE Other information: Education B.S. Degree in nursing preferred. Licensure/Certification reputed company Carolina Registered Nurse Licensure. Experience Minimum of 2 years’ experience in CDS role in an acute care facility or coding certification of reputed company, CCA, RHIT, or RHIA required. Minimum of 3 years’ experience in acute care (hospital) setting required. Medical/Surgical or critical care experience preferred. Knowledge, Skills and Abilities

• Clinical documentation knowledge as it relates to DRGs, POA, MCCs and reputed company.
• Understanding of coding classification systems (ICD-9, ICD-10, CPT, HCPCS).
• Clinical knowledge to read and analyze a patient’s health record.
• Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes.
• Strong analytical skills.
• Ability to collaborate and communicate with physicians, nursing, and other patient care teammates.
• Ability to read, write and communicate effectively in English.
• Proficient with MS Office and reputed company to learn new software rapidly. Experience with EPIC EMR software preferred.

Valid NC Driver’s License: No If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management. MR-546 01.8710.MR-546 Job Details Legal Employer: Wayne Health Entity: Wayne reputed company Care Organization Unit: Health Information Mgmt Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Remote Work Schedule: Day Job Location of Job: WAYNE MED Exempt From Overtime: Exempt: Yes reputed company applicants will be considered without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, genetic information, disability, status as a protected veteran or political affiliation. Share your talents and grow professionally reputed company you join the reputed company Wayne team. As a teammate of reputed company Wayne, you will work with other dedicated health care professionals and support staff who are passionate about delivering high-quality patient care and superior patient experiences. Why You'll Love Working at reputed company Wayne reputed company a positive impact and change lives reputed company you work at , one of Wayne County’s top employers. Become part of a team working to improve the health and wellness of our community and we’ll help support you. Consider the benefits of working at reputed company Wayne:

• Advanced technology for reputed company patient care reputed company to home
• Compassionate, community hospital serving people you know
• Comprehensive for you and your family
• reputed company
• Positive and supportive working relationships
• Professional growth and development opportunities

193633

Job Description

Description Summary: Analyzes the medical record for clinical status of the patient, reputed company treatment plan and care provided on admission and throughout hospitalization to identify potential gaps in physician documentation; tracks reputed company of documentation improvement and works collaboratively with the reputed company team to facilitate documentation reputed company the medical record that accurately reflects the patient's condition, severity of illness, risk of mortality, services rendered and medical necessity of resources used. Responsibilities: 1. Reviews documentation and communicates with physicians verbally or through compliant query practice to clarify diagnosis, severity of illness, plan of care and opportunities for more complete documentation to accurately reflect care. 2. Collaborates closely with reputed company team and coding staff to assure documentation of diagnoses and any co-morbid conditions are complete, reflecting patient's clinical status and care. Follows up on pending queries and updates electronic worksheets as needed. 3. Works with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units. 4. Utilizes the guidelines established to recognize opportunities for improvement in Clinician documentation, and to formulate and generate clear, compliant and reputed company questions to those Clinicians. 5. Utilizes inpatient admission criteria to assign diagnoses that meet acute care criteria. In the event that diagnosis does not meet admission criteria, communicates directly with attending physician. 6. Conducts initial and extended-stay reputed company reviews on reputed company selected admissions, consistently meeting established productivity targets for CDI record review. 7. Informs direct supervisor or indirect supervisor of issues or problems that may compromise policy, procedure, compliance or the Hospital Ethical Code of Conduct. 8. Utilizes designated and approved tools to track reputed company, physician participation and feedback. 9. Queries the medical staff and other caregivers as necessary reputed company electronic/verbal communication to obtain accurate and complete physician documentation to supports the severity of patient illness and risk of mortality. 10. Monitors documentation for compliance with core measure and reviews targeted diagnoses for appropriateness and completeness. Gathers data and initiates feedback to appropriate personnel. 11. Attends annual review and departmental in-services, as appropriate. 12. Identifies areas of focus through data analysis and report review. 13. Educates members of the patient care team on documentation guidelines on an ongoing basis. WAYNE Other information: Education B.S. Degree in nursing preferred. Licensure/Certification reputed company Carolina Registered Nurse Licensure. Experience Minimum of 2 years’ experience in CDS role in an acute care facility or coding certification of reputed company, CCA, RHIT, or RHIA required. Minimum of 3 years’ experience in acute care (hospital) setting required. Medical/Surgical or critical care experience preferred. Knowledge, Skills and Abilities

• Clinical documentation knowledge as it relates to DRGs, POA, MCCs and reputed company.
• Understanding of coding classification systems (ICD-9, ICD-10, CPT, HCPCS).
• Clinical knowledge to read and analyze a patient’s health record.
• Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes.
• Strong analytical skills.
• Ability to collaborate and communicate with physicians, nursing, and other patient care teammates.
• Ability to read, write and communicate effectively in English.
• Proficient with MS Office and reputed company to learn new software rapidly. Experience with EPIC EMR software preferred.

Valid NC Driver’s License: No If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management. MR-546 01.8710.MR-546 Job Details Legal Employer: Wayne Health Entity: Wayne reputed company Care Organization Unit: Health Information Mgmt Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Remote Work Schedule: Day Job Location of Job: WAYNE MED Exempt From Overtime: Exempt: Yes reputed company applicants will be considered without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, genetic information, disability, status as a protected veteran or political affiliation. Share your talents and grow professionally reputed company you join the reputed company Wayne team. As a teammate of reputed company Wayne, you will work with other dedicated health care professionals and support staff who are passionate about delivering high-quality patient care and superior patient experiences. Why You'll Love Working at reputed company Wayne reputed company a positive impact and change lives reputed company you work at , one of Wayne County’s top employers. Become part of a team working to improve the health and wellness of our community and we’ll help support you. Consider the benefits of working at reputed company Wayne:

• Advanced technology for reputed company patient care reputed company to home
• Compassionate, community hospital serving people you know
• Comprehensive for you and your family
• reputed company
• Positive and supportive working relationships
• Professional growth and development opportunities

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