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Form of workJob Summary:
The Clinical Documentation Auditor/Educator will provide review of inpatient medical records to evaluate the diagnosis and procedural code assignment as an accurate and appropriate representation of the documentation and utilization of acute care services. As a Clinical Documentation Auditor/Educator the role will include facilitation of appropriate diagnosis and procedure code assignment and physician documentation of care to accurately reflect patient severity of illness and risk of mortality and accurate MS-DRG assignment. The auditor reviews inpatient records to assure accurate DRG assignment; including ICD-9-CM/PCS and/or ICD-10-CM/PCS, present on admission indicators, discharge disposition, coding and documentation of HACs and PSIs as well as appropriateness of concurrent and retrospective queries. He/she will educate Erlanger staff on findings from audits, record reviews and changes in Coding, DRG assignment to facilitate accurate and complete documentation.
The Auditor/Educator maintains proficiency in the Official Coding Guidelines for coding and reporting and the AHA Coding Clinics
Education:
Required: BS in Health Information Administration or AS in Health Information Technology and CCS or Registered Nurse in the State of TN with CCS.
Preferred: Masters Degree in Business or health related field
Experience:
Required: At least five years inpatient coding experience, ICD 10 training certification and at least three years teaching experience at all levels - physician, nursing and coding.
Preferred: Working knowledge of CDI processes
Required Skills:
The candidate must have proven strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes, excellent written and verbal communication skills and critical thinking critical thinking skills. He/She must be able to work independently in a time-sensitive environment. He/She must demonstrate expertise in ICD10 training and maintain certified status.
Assertive personality traits will facilitate ongoing physician communication and provide the interpersonal skills to build effective relationships with physicians, nursing staff, hospital leadership, health information systems and coding staff. Computer literacy and familiarity with the 3M Encoder and Microsoft Office Software is a must.
Position requirements/Licensure:
Required: RHIT or RHIA or current RN License to practice in the State of TN, if applicable. If required Certified as CCS
Preferred: CDIP strongly preferred
DEPARTMENT JOB SUMMARY
The Auditor/Educator analyzes, evaluates, audits and/or reviews inpatient records including Fair Code cases as directed by the Inpatient Coding Manager. He/She may also audit medical and billing records to determine opportunities to improve specificity, meet increased documentation requirements within ICD-9 CM and ICD-10 CM/PCS, and evaluate conformity to coding guidelines. Scope of work may include but will not be limited to ICD-10 Clinical Documentation gap analyses, general Clinical Documentation and coding reviews , charge to chart audits, grouping system validations (i.e., MS-DRG, APR-DRG, APCs, APGs, etc.), and other coding and Clinical Documentation as assigned by the Inpatient Coding Manager.
He/She must abide by the AHIMA Code of Conduct and Standards of Ethical Coding as set forth by AHIMA and communicate in a clear, respectful and understandable manner. The Auditor /Educator uses only commonly accepted and official reference materials and tools to ensure accuracy of review and recommendations provided. He/ She demonstrates exemplary attention to detail with a thorough understanding of government rules, regulations and areas of scrutiny for potential areas of risk for fraud and abuse in regards to coding and documentation.
