Company: Trinity Health
Job description: Employment Type: Full time
Shift: Day Shift
Description:
Experienced Clinical Documentation Specialist St Peters Hospital
If you are looking for a Clinical Document Specialist position in Acute, to meet your schedule, this could be your opportunity. Here at St. Peter's Health Partner's, we care for more people in more places.
Position Highlights:
- Recognized leader: Magnet Hospital in the Capital Region
- Quality of Life: Where career opportunities and quality of life converge
- Advancement: Generous tuition allowance and career development
- Work/Life: Positions and shifts to accommodate all schedules and possibility of working remote
- To provide clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patient's diagnoses and procedures.
- The goal of concurrent review is to facilitate clinically appropriate physician/clinical documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.
- Utilizes electronic tools and reports to identify and prioritize case reviews, follow up reviews and outstanding queries.
- Utilizes critical thinking skills to perform concurrent reviews of clinical documentation in the medical record. The initial review is performed within 24-48 hours of admission.
- Analyzes the patients current clinical status, treatment plan and past medical history to identify potential gaps in physician documentation.
- Identifies the principal diagnosis and all secondary conditions, co-morbidities, complications and procedures that have been documented in the medical record.
- Evaluates POA indicators for each diagnosis that could potentially affect the principal diagnosis, quality indicators or DRG assignment.
- Assigns the working DRG(s) to each case.
- Queries the physician, resident/intern, mid-level clinicians and other clinicians for clarification or to obtain accurate and complete documentation as needed, based on current clinical findings, prescribed treatment, medical interventions and/or procedures.
- Performs follow up reviews (non query) of the medical record every 2-3 days.
- Outstanding queries are re-reviewed the next day for physician response and appropriate follow up interventions are initiated to facilitate timely and accurate documentation.
- Applies knowledge/skills regarding coding conventions, coding guidelines and coding clinics when reviewing the medical record and assigning DRG's.
- Adheres to the Clinical Documentation processes, workflow and priority DRG review process.
- Adheres to Trinity/Department policy on writing an effective and complaint query.
- Achieves minimum departmental productivity standards of 25-30 reviews per day, inclusive of initial and re-reviews.
- Achieves program benchmarks for query rate of 35-45% and physician response rate of greater than 85 % and provider agreement rate of greater than 90%..
- Identifies core measure principal diagnosis for CHF and pneumonia.
- Identifies, reviews and collaborates with the health navigator on bundled payments.
- Performs retrospective medical record reviews as needed.
- Contributes/participates in orientation of new staff and team members.
- Applies knowledge of legal, ethical and regulatory boundaries of documentation and coding in daily Clinical Documentation practice.
- Maintains professional integrity and confidentiality of information in accordance with applicable policies, procedures, state and federal requirements.
EDUCATION REQUIREMENTS:
- Graduate of Nursing School, Bachelor's degree preferred in Health Care field
- Current New York State License
- CCDS/CCS certification preferred
- Minimum 5 years clinical experience with acute care inpatient experience
- Critical care or strong Medical/Surgical experience.
- Has demonstrated assertive personality traits and excellent interpersonal/physician relationships in the past, and has the ability to maintain those going forward.
- Exceptional written and verbal communication skills.
- Previous Clinical Documentation experience preferred.
- Experience with criteria-based chart review, such as Case Management, Utilization Management, Managed care, Quality Improvement.
- Highly developed organization, critical thinking and analytic skills.
- Computer literacy; competent with Microsoft Office, internet search, data entry and reporting software.
- Ability to proactively form positive, collaborative relationships with physicians, residents/interns, mid-level clinicians, coders and other health care professionals.
- Dependable and self-directed with the ability to successfully multitask and manage conflicting priorities.
- Knowledge of healthcare regulations, including Medicare reimbursement system, coding structure and documentation requirements preferred.
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
Expected salary:
Location: Albany, NY Apply Now