Kadlec Clinical Documentation Improvement Specialist in Richland, Washington
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Kadlec Regional Medical Center has an exciting opportunity for a Clinical Document Improvement Specialist to join our growing team!
Shift Details: Full-time, Day Shift, 1.0 FTE
Graduation from an accredited nursing program required.
Current Washington State Registered Nurse Licensure required.
Five years clinical experience in an acute care facility, which includes broad clinical experience in an inpatient setting or clinical documentation experience required.
Bachelor’s Degree in Nursing and/or Healthcare related field from an accredited educational institution preferred.
RN with CCScertification preferred.
Duties include, but are not limited to, the following:
As the Clinical Documentation Improvement (CDI) Specialist you will coordinate and collaborate extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation through concurrent (pre-bill) interaction; Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant patient populations; and provides education to physicians and members of the patient care team on an ongoing basis.coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation through concurrent (pre-bill) interaction; Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant patient populations; and provides education to physicians and members of the patient care team on an ongoing basis.
• Demonstrate and sustain compliance with Kadlec Caregiver Expectations Standard of Excellence and Code of Conduct.
• Educate patient care team members on clinical documentation opportunities, coding, and reimbursement issues.
• Review inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Collaborate with providers, case managers, coders and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses and interventions.
• Interact with physicians, providing them with feedback and education on documentation issues.
• Facilitate modifications to clinical documentation to support appropriate reimbursement for the level of service rendered to all patients with a MS-DRG or AP-DRG based payor (Medicare, Medicaid, Premera, etc).
• Demonstrate knowledge of DRG payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
• Collaborate with case managers to ensure continuity of patient care and validates clinical documentation with plan of care.
• Conduct follow-up of CDI queries to ensure that physician responses have been appropriately documented.
• Provide or coordinates education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with various multidisciplinary healthcare teams.
• Maintain thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Handle highly confidential and sensitive information with discretion according to HIPAA rules and regulations.
• Update the CDI application with information regarding discharges to reflect any changes in status, procedures/treatments.
• Assist with special projects as needed.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician-specific data information.
• Enhance expertise in query development, presentation, and standards (including understanding of published query guidelines and practice expectations for compliance).
• Work with Hospitalists to ensure core measures are met and forms are filled out appropriately.
• Advise and consults with EPIC analysts or educators in regards to electronic health record development to ensure the enabling of CDI efforts (i.e. physician template review).
• Participate in monthly efficiency and quality review with hospitalist team and assists in developing plan of action for improvement of clinical documentation.
• Communicate quality concerns through the appropriate, established channels and supports opportunities for performance improvement.
• Seek out changes in healthcare reform and coding regulations then incorporate those changes into chart review and educational responsibilities.
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Provide safe compassionate care. We promise to answer the call of every person we serve; to know them, care for them and ease their way. We are committed to safety, compassion, respect, integrity, stewardship, excellence and collaboration.
Located in sunny Tri-Cities, WA, Kadlec is the largest non-profit healthcare provider in the region. Kadlec is the premier choice for customer service excellence, providing compassionate healthcare by combining cutting-edge technology and innovation with evidence-based, patient-focused care. Kadlec does not unlawfully discriminate on the basis of race, sex, sexual orientation, age, color, religion, national origin, genetic information, marital status, veteran status, disability status, or any other characteristic protected by Federal, State, or Local Law. EOE. To learn more, click here: https://kadlec.jobs/about-us/
Job Category: Clinical Lead Supervisor/Manager
Req ID: 314564