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IntelassistClinical Documentation Specialist
Clinical Documentation Specialist ensuring accuracy and completeness of clinical documentation for healthcare providers. Collaborating with medical staff to meet compliance and regulatory standards.
About the role
- Completes initial patient medical record review within 24-48 hours of patient's admission; completes subsequent reviews of patient's medical record reviews every 24-48 hours and enters review findings in CDE software system
- Assigns Principal diagnosis, CC/MCC (complication and comorbidity/major complication and comorbidity), evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house.
- Assigns working ICD-10-CM and PCS codes and DRG (Diagnosis Related Group) using encoder in CDE software.
- Clarifies with physicians regarding missing, unclear, unsupported or conflicting health record documentation by requesting and obtaining additional documentation from physicians when needed.
- Face to face physician interaction and written clarifications are used.
- Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record.
- Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment.
- Reviews DRG denial letters and writes denial appeal letters.
- Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.
- Maintains and upholds all clinical documentation regulatory guidelines
- Formulates and submits timely, well prepared appeals for reconsideration by third party administrators (payors). Including supporting documented clinical evidence, Coding/CDE Guidelines and other regulatory standards/guidelines as appropriate.
- Works collaboratively with co-workers and management to effectively resolve root cause issues that impact payor contracts, hospital operations, or departmental to maintain reimbursement and minimize appeal requests and/or denials.
Requirements
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience
- Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations
- Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills
- Minimum Education Current RN Licensure
- Certifications: CRCR Required within 9 months of hire
Benefits
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
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