CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST Job at Toledo Clinic
General Summary:
Educate providers on effectively documenting the patient’s severity of illness, physician clinical judgment and medical decision making in support of medical necessity and appropriate CPT and diagnosis coding.
Principal Duties & Responsibilities:
1. Review of patient health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.
2. Educate providers on how to document continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress” of the patient.
3. Train providers on how to facilitate complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient’s primary care physician.
Required:
- Strong clinical documentation knowledge, to completely and accurately report on patient services provided.
- Knowledge of ICD-10-CM, CPT and HCPCS Official Coding Guidelines.
- General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
- Practical knowledge and understanding of official E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity.
- Effective ability and willingness to communicate benefits of complete and accurate documentation to providers relating to their daily practice of medicine.
- Commitment to maintain knowledge in and familiarity of constantly changing updates in the business of medicine directly impacting the practice of medicine and providers.
- Demonstrated understanding of documentation relevant to denial avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs.
- Ability to review medical necessity denials and provide constructive feedback to providers.
- Ability to work with all provider specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each provider on an “as you go” basis.
- Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame.
- Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed.
- Flexibility and ability to adjust to a constantly changing work environment
- Adheres to clinic’s policies and procedures
Education:
RHIT and clinical license or/certification required; CCDS and/or CDS preferred.
Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD10 and ability to educate physicians on the merits of preparation as the best practice strategy in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician’s, updates from CMS carriers effecting physicians such as billing, documentation, and coding guidelines and policies.
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