Clin Document Integrity Spec

GENERAL SUMMARY :

Facilitates integrity in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Medical Records coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate.

Educates all members of the patient care team on documentation guidelines on an ongoing basis.

CORPORATE PHILOSOPHY :

It is the obligation of each employee of Edward - Elmhurst Health to abide by and promote the mission and values of the System to ensure that excellent services are delivered with compassion.

PRINCIPAL DUTIES AND RESPONSIBILITIES : (The following duties and responsibilities are all essential job functions, as defined by the ADA, except those that begin with the word "May.")

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED :

Reviews clinical documentation and facilitates clarifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, severity of illness, and conditions present on admission for all patients, in compliance with government regulations and ACDIS / AHIMA practice standards.

Initiates inpatient chart review of provider documentation, lab and diagnostic treatment results, and plans of care typically within 48 hours of admission.

Conducts follow-up reviews at regular intervals, in general not to exceed 4 days, to ensure that the working DRG is accurate and documentation is complete.

Conducts retrospective review of cases when requested by the HIM coding team. Reviews may include evaluation of mortalities for complete documentation, and cases with triggered patient safety indicators and hospital acquired conditions to ensure that they are accurately assigned.

Develops queries per departmental guidelines when opportunities to clarify documentation are identified. Follows up with physician or advanced practice clinician to ensure that queries are completed.

Initiates referrals to staff in the quality department when potential issues are identified during review. Records and maintains an ongoing record of the results of each chart review in the dedicated CDI data base.

Serves as a resource to physicians and other members of the healthcare team in matters relating to DRG assignment, ICD 10 code assignment, and assignment of SOI / ROM scores.

Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Briefs, ACDIS Code of Ethics, and official Coding Guidelines Reconciles DRG discrepancies collaboratively with HIM team to ensure an accurate compilation of the final codes.

Provides periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on- one and group forums.

Develops and disseminates approved documentation improvement literature. Works with HIM, finance and physician groups to develop work systems / processes to facilitate complete documentation for data reporting purposes.

Required Education and / or Experience : Minimum Associate’s Degree in Nursing or Health Information Management (HIM) Preferred Education and / or Experience : Bachelor’s Degree in Nursing Minimum 5 years of clinical (nursing and / or HIM) experience Previous experience in clinical documentation integrity Required License and / or Certification : Current State of Illinois Registered Nurse license or Registered Health Information Technician (RHIT) certification or Registered Health Information Administrator (RHIA) certification