Clinical Documentation Specialist

Job Description

The goal of the Clinical Documentation Specialist-Consultant is to educate leaders, physicians, advanced practice providers (APP), and other staff about documentation and risk adjustment in order to improve the accuracy of the overall clinical picture and the representation of the complexity and severity of illness of patients through improved clinical documentation and diagnostic coding practices.

Schedule - Monday - Friday this position is a hybrid position to local Nevada applicants onl

• Assesses needs and develops, evaluates, and implements education plans, interventions, and training.
• Acts as an education leader, consultant, and mentor to leaders, physicians, APP's, and other staff about documentation and risk adjustment.
• Reviews medical records documentation for reimbursement, severity of illness and risk of mortality.
• Identifies opportunities for improving the quality of medical record documentation and confers with the caregiver regarding additional documentation required.
• Collects statistics from the reviews and maintains accurate records to document costs and benefits.
• Facilitates and enhances the coding and diagnosis-related group between physician and coding staff.

Minimum Qualifications

Bachelor's degree in a clinical field (, RN, RRT, PT, OT, SLP, LCSW). Education must be obtained through an accredited institution.

Degree will be verified.

• Clinical license in state of practice (, RN, RRT, PT, OT, SLP, LCSW).
• Depending upon your clinical licensure, equivalent experience may substitute the degree requirement.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements list must be representative of the knowledge, skills, minimum education, training, licensure, experience, and / or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Knowledge of CMS Medicare, Medicaid, Managed Care and Commercial health plan billing, reimbursement and regulations.
• Knowledge of quality measures, patient safety indicators, value-based purchasing, risk adjustments, mortality scoring, hospital acquired conditions, CMS 5 star, and external publicly reported quality metrics.
• Knowledge of how ICD codes, DRGs and SOI / ROM scores are used for reimbursement, public reporting or outcomes, reviewing quality of patient care, financial modeling, strategic planning and marketing.
• Knowledge of compliance, practice briefs, white papers, and other publications guiding ethical and legal practices of CDI.
• Knowledge of ICD-10-CM, ICD-10-PCS, Official Coding Guidelines, Coding Clinics, and other guiding references for coding accuracy and compliance.
• Knowledge of clinical criteria, pathophysiology, evidence-based practice and the ability to stay current on new trends in medical treatment.

Ability to articulate concepts to physicians and other health care professionals to educate on clinical documentation requirements.

Strong communication skills in order to successfully communicate complex ideas across different groups and educate on areas of needed improvement.

Ability to act as a translator between clinical and non-clinical teams. Ability to work collaboratively with diverse groups and to effectively persuade and lead individuals / groups toward consensus.

• Possess strong critical thinking with the ability to autonomously prioritize work, manage time, and maintain organization to support efficiency and effectiveness.
• Proficient with multi-platform computer software and applications in order to utilize tools appropriately to track, analyze, calculate, and summarize data and qualitative findings.

Preferred Qualifications

• Experience in Clinical Documentation Integrity.
• Experience with Microsoft Office products.
• Clinical experience in ICU, CCU, primary care, or intermediate care.
• Knowledge of Electronic Medical Record tools such as iCentra, Epic and Help2 systems.

Physical Requirements :

• Interact with others requiring employee to verbally communicate as well as hear and understand spoken information.
• Operate computers, telephones, office equipment, including manipulating paper requiring the ability to move fingers and hands.
• See and read computer monitors and documents.
• Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment.

Anticipated job posting close date :

09 / 18 / 2024

Location :

Nevada Central Office

Work City : Las Vegas

Las Vegas

Work State : Nevada

Nevada

Scheduled Weekly Hours :

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$ - $

We care about your well-being mind, body, and spirit which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers, and for our Colorado, Montana, and Kansas based caregivers;

and our commitment todiversity, equity, and inclusion.

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.