Clinical Documentation Spec - HIM-Clinical Doc Integrity - 016

Job Duties & Responsibilities

Daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.

Ensures that the medical record documentation provides an accurate representation of the patient’s clinical care, diagnosis, severity, and expected risk of mortality sufficient to support APR-DRG assignment.

Communicates with physicians and other healthcare team members, 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.

Demonstrates 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.

Utilizes nursing critical thinking to identify clinical indicators for potential physician queries.

Provides concurrent review and analysis of clinical information through electronic medical record review and interactions with providers.

Acts as a liaison between hospital’s medical staff and coding/CDI team.

Fosters cooperative relationships between medical staff and all CDI team.

Participation in process improvement and education for CDI program.

Reporting and analysis of data for CDI program.

Actively participates in departmental and hospital committees and assigned Task Force groups

Complies with HIPAA (Health Insurance Portability and Accountability Act of 1996) and all Hospital Policies and Procedures.

Maintains interaction with appropriate resources that support growth and education of the CDI team.

As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.

Skills & Requirements

Required associate degree with a preferred bachelor's degree

Required Licenses/Certifications

MDL - Medical Doctor License Texas Medical Board

RN - Lic-Registered Nurses Texas Board of Nursing or Nurse Licensure Compact

PA - Cert-Physician Assistant Texas Medical Board

RHIA - Cert-Reg Health Inform. Admins American Health Information Management Association (AHIMA)  

RHIT - Cert-Reg Health Inform. TECH American Health Information Management Association

CCS - Cert-Cert Coding Specialist American Health Information Management Association  

CPC - Cert-Cert Professional Coder America Association of Professional Coders

CCDS DOC - Cert-Cert Clinical Doc. SPCLST Association of Clinical Documentation Improvement Specialist

CDIP - Cert-Clinical Doc. Impr. PROF American Health Information Management Association

Preferred Pediatric experience

Nurse with an associate or preferably a bachelor's degree in nursing, NP, PA, MD

Pediatric nursing experience