CLINICAL DOCUMENTATION IMPROVEMENT CODER
- Req #: 8276
- Address: 2100 Sherman Ave
- City, State: Norwood, OH
- Zip: 45212
- Type: Full time
- Shift: Day
Job Description
Responsible for improvement in the overall quality, completeness, and accuracy of physician documentation in the medical record. Obtains appropriate clinical documentation through interactions with physicians and nursing staff to ensure that the clinical documentation reflects the level of service rendered to patients is accurate and complete. Provides education on documentation guidelines to all members of the patient care team on an ongoing basis.
Responsibilities
1. Program Development and Enhancement
• Update and maintain query templates according to AHIMA's Guidelines for Achieving a Compliant Query Practice
• Physician training on documentation opportunities and current coding guidelines
• Reviews inpatient accounts in DRG Review WQ for missing "MCCs" and "CCs"
2. Daily Operations
• Queries physicians on a retrospective basis. Works with physicians to clarify documentation in the medical record.
• Follows each query through to closure including completing a log of ongoing follow up activities and communication.
• Contact non-compliant physicians
• Identify areas of process improvement and actively work toward resolution with the CDI team
• Follow up on educational and coding guidelines opportunities identified by the query process
• Resolves DRG issues with the Coding Manager and Coding Improvement Coordinator
• Develops and supports strong professional relationships with CDS, Coding staff, Quality department, and medical providers.
• Meets and maintains program goals
• Evaluates associate performance and provides input to coding manager
3. Physician Liaison
• Provides clarification regarding disease process and procedures
• Bridges the gap between documentation and coding regulations
• Assists in drafting newsletter articles regarding documentation requirements for physician audiences
• Provides physician feedback regarding documentation
4. Interdepartmental Collaboration
• Works with IP Rehab unit on coding for IRF-PAI and CMG code submission to CMS.
• Reviews inpatient documentation to justify the coding of a Never Event. Reviews coding for PSI and HAC accounts. Enters queries if appropriate for further clarification.
• Works in EIQ system for retrospective DRG Validation. Enters queries on accounts that have query recommendations. Enters notes in EIQ to communicate the status of the account. Rebills as appropriate after completion.
5. Actively participates in:
• Monthly Coder/CDI Meeting
• Weekly Quality PSI/HAC Review
• Other hospital operation/clinical meetings
6. Other duties as assigned
Qualifications
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: Associate or Bachelor's degree preferred
YEARS OF EXPERIENCE: 10+
REQUIRED SKILLS AND KNOWLEDGE: Demonstrates facilitation and presentation skills. Ability to work collaboratively with medical staff (physicians), nursing and coding staff. Superior communication skills. System experience, critical thinking skills and problem-solving skills are a must. Must have advanced coding skills and an understanding of coding regulatory guidelines.
LICENSES & CERTIFICATIONS:
The following certifications are preferred:
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Coding Associate (CCA)
• Certified Professional Coder (CPC)
Responsible for improvement in the overall quality, completeness, and accuracy of physician documentation in the medical record. Obtains appropriate clinical documentation through interactions with physicians and nursing staff to ensure that the clinical documentation reflects the level of service rendered to patients is accurate and complete. Provides education on documentation guidelines to all members of the patient care team on an ongoing basis.
Responsibilities
1. Program Development and Enhancement
• Update and maintain query templates according to AHIMA's Guidelines for Achieving a Compliant Query Practice
• Physician training on documentation opportunities and current coding guidelines
• Reviews inpatient accounts in DRG Review WQ for missing "MCCs" and "CCs"
2. Daily Operations
• Queries physicians on a retrospective basis. Works with physicians to clarify documentation in the medical record.
• Follows each query through to closure including completing a log of ongoing follow up activities and communication.
• Contact non-compliant physicians
• Identify areas of process improvement and actively work toward resolution with the CDI team
• Follow up on educational and coding guidelines opportunities identified by the query process
• Resolves DRG issues with the Coding Manager and Coding Improvement Coordinator
• Develops and supports strong professional relationships with CDS, Coding staff, Quality department, and medical providers.
• Meets and maintains program goals
• Evaluates associate performance and provides input to coding manager
3. Physician Liaison
• Provides clarification regarding disease process and procedures
• Bridges the gap between documentation and coding regulations
• Assists in drafting newsletter articles regarding documentation requirements for physician audiences
• Provides physician feedback regarding documentation
4. Interdepartmental Collaboration
• Works with IP Rehab unit on coding for IRF-PAI and CMG code submission to CMS.
• Reviews inpatient documentation to justify the coding of a Never Event. Reviews coding for PSI and HAC accounts. Enters queries if appropriate for further clarification.
• Works in EIQ system for retrospective DRG Validation. Enters queries on accounts that have query recommendations. Enters notes in EIQ to communicate the status of the account. Rebills as appropriate after completion.
5. Actively participates in:
• Monthly Coder/CDI Meeting
• Weekly Quality PSI/HAC Review
• Other hospital operation/clinical meetings
6. Other duties as assigned
Qualifications
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: Associate or Bachelor's degree preferred
YEARS OF EXPERIENCE: 10+
REQUIRED SKILLS AND KNOWLEDGE: Demonstrates facilitation and presentation skills. Ability to work collaboratively with medical staff (physicians), nursing and coding staff. Superior communication skills. System experience, critical thinking skills and problem-solving skills are a must. Must have advanced coding skills and an understanding of coding regulatory guidelines.
LICENSES & CERTIFICATIONS:
The following certifications are preferred:
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Coding Associate (CCA)
• Certified Professional Coder (CPC)
