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Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.
Position Overview:
- Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Proactively identifies issues with reporting of diagnostic testing.
- Educates physicians and key healthcare providers regarding Clinical Documentation improvement and the need for accurate and complete documentation in the health record.
- Performs physician formal education sessions when indicated.
- Collaberates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
- Assists with preparation and presentation of Clinical Documentation monitoring/trending reports for review with physicians and hospital leadership.
- Attends hospital or Medical Staff meetings to review or respond to documentation related issues.
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and appregate data analysis.
- Provides technical assistance to the Medical Staff and patient care providers to efficiently navigate the electronic medical which could reside in multiple systems.
- Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
- Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
- Partners with the billing staff to ensure the integrity of our charge capture system and perform records and charge reviews for certain payer populations.
- Facilitates change processes required to capture needed documentations, such as forms redesign.
- Promotes collaborative working relationships with team leaders from all clinical areas in relationship to documentation.
- Proactively troubleshoots documentation or communication problems and appropriately escalates to senior level.
- Assists in the appeal process resulting from third-party reviews.
- Maintains a level of expertise by attending continuing education programs.
- Maintains appropriate productivity level.
MINIMUM REQUIREMENTS
- Education: Graduate of an accredited school of nursing program. BSN preferred.
- Experience: Three years recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three years related coding experience or Clinical Documentation Improvement Specialist experience in a hospital setting.
- Knowledge and Skills: Excellent verbal and written communication skills. Strong critical thinking skills. Working knowledge of all areas of adult medicine. Knowledge of pathophysiology and disease process. Intermediate computer skills. Familiarity with windows based software programs.
- Mental, Behavioral and Emotional Abilities: Excellent observation, analytical thinking, and problem solving skills. Ability to learn/develop skills necessary to perform CDI. Flexible, dependable and self-directed. Ability to work independently. Demonstrates ethical conduct.
- Usual Work Day: 8 Hours
PHYSICAL DEMANDS AND WORK ENVIRONMENT
- Frequent physical demands include: Wrist position deviation , Pinching/fine motor activities
- Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl
- Continuous physical demands include: Sitting , Keyboard use/repetitive motion , Talk or Hear
- Lifting Floor to Waist 25 lbs. Lifting Waist Level and Above 25 lbs.
- Sensory Requirements include: Accurate Near Vision, Minimal Hearing
- Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease , Uneven Surfaces or Elevations , Dust/Particulate Matter
Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.
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