DOCUMENTATION SPEC-SOC SERVICE
Aultman Health FoundationCANTON, Ohio, United States, 44702job_description.job_card.variable_days_ago
serp_jobs.job_preview.job_type
- serp_jobs.job_card.full_time
job_description.job_card.job_descriptionProvide feedback to the front-line CDSs based on opportunities and trends identified through the second level reviews Track technology issues with process tools and coordinate with IT on updates Track query escalation process, CDS / Coder collaboration, etc. Lead weekly huddles or monthly meetings for CDI and Coding teams. Conduct audits of CDI queries and perform second level reviews Identify DRG mismatches and collaborate with Coding team on reconciling Determine individual physician and service line educational needs Assist management with external and internal CDI data requests. Work closely with external CDI consultants to determine any educational opportunities identified via external reporting or chart reviews Reviews the progress of program, reporting to the manager, through regular interpretation of process and operational reports, financial and compliance reports, and quality rating reports. Able to identify areas of focus and necessary process refinements through report analysis. Provides guidance and support to the CDI team in enacting process changes and evaluating results. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment Assists with various training and operational matters including appropriate scheduling and coverage of cases, reconciling queries and DRG discrepancies, educating physicians, monitoring the program, and refining the process as needed, as well as training and mentoring new and current CDSs Support and assist manger on the second level review process including determining the focus of reviews and adjusting based on opportunities identified in the data. Conduct targeted second level reviews (SLR) along with other CDSs, which aims to identify additional opportunities beyond what the initial CDI process identified. Cases flagged for SLRs are based on selected criteria as provided by CDI Management and are intended to address any further gaps in the documentation prior to the billing of the chart. The approach to SLRs should be a holistic review of the entire patient stay. Lead CDS to provide feedback to the frontline CDSs based on opportunity trends identified through the SLR process As requested by the CDSs for assistance on select cases, conducts initial and extended-stay concurrent reviews on selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of patient acuity, and documents findings within the CDS tracking software, denoting all key information utilized in the tracking process Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, utilization reviewer, nurse, or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the patient’s severity of illness and risk of mortality Required Knowledge, Skills, and Working Conditions : Extensive clinical knowledge and understanding of pathology / physiology; best demonstrated by clinical experience in hospital setting Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues Knowledge of age-specific patient needs and the elements of disease processes and related procedures Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers Assertive personality traits to facilitate ongoing physician communication Working knowledge of inpatient admission criteria Ability to work independently in a time-oriented environment Ability to stand and walk in the performance of job responsibilities Current RN license Inpatient bedside nursing Case management Previous CDI experience
DOCUMENTATION SPEC-SOC SERVICE
General Statement of Duties :
Run and review reports through several sources and utilizing information to :
- Analyze data and key metrics to identify potential opportunities for CDI staff and physicians
- Strategize approach and process refinements to capture opportunity within the CDS team (prioritization, assignment, etc.)
- Track progress of CDI team in capturing opportunities and prioritizing workload effectively
- Assist with development and maintenance of training and orientation program for new CDSs
conduct second level reviews of targeted cases.
Provide feedback and educational growth opportunities to the CDI team
Provide feedback to physician advisor(s) on provider engagement / response
Create and present targeted physician education
Typical Responsibilities and Allocation of Time :
50% - Oversight and Education
50% - Review
Acceptable Experience Backgrounds :
Minimum of 5 years of clinical experience in an acute care setting. Backgrounds include :
PI13ea05e48e4b-30511-38661334
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Documentation • CANTON, Ohio, United States, 44702
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