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Form of workOverview:
USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
Identifies documentation deficiencies that inhibit accurate, complete and timely coding for billing and reimbursement; trains physicians to document complete and accurate records of patients’ conditions, treatments, severity of illness, and complexity of care required for coding; stays abreast of Joint Commission Standards, CMS Standards, and American Hospital Association “Coding Clinic” Standards related to documentation requirements; assists in the development of a concurrent documentation review process to evaluate effective physician and staff documentation related to MS-DRG’s, APR-DRG’s, and Present On Admission (POA) assignments; assists coding staff in the writing of physician queries and makes contact with physicians to clarify, train, and complete documentation prior to billing; reviews records where auditors have changed code assignments due to lack of documentation; notifies staff of documentation deficiencies and the impact they have on reimbursements; maintains a database of records reviewed, problems identified, physicians involved, actions taken, and improvements made; reports findings to supervisor, coding staff, and various committees as required; prepares and distributes information to physicians regarding new documentation requirements as it relates to coding requirements; acts as liaison between coders and physicians to facilitate Clinical Documentation Improvement; works collaboratively with Care Management staff to facilitate Clinical Documentation Improvement; provides education and feedback to residents, faculty, private physicians, and staff regarding appropriate documentation and coding; identifies patterns and trends of inappropriate/inaccurate documentation and initiates a corrective action plan; maintains a clean work environment; maintains an adequate inventory of supplies for the department; utilizes and accesses the Hospital Information System (Cerner), 3M, EDM, Soarian Clinicals, CribNotes, OB TraceVue, Vincari and Command Health; assists supervisor in identifying resource needs as well as informing supervisor when supplies are low; informs/relays information to incoming shifts regarding any unfinished requests/duties; participates in the orientation of new employees; demonstrates ability to articulate documentation requirements to physicians in order to educate and assist with the teaching needs as it relates to documentation for coding and reimbursement; communicates and uses appropriate customer relation skills with physician, patients, families, and healthcare team in person and by telephone; accepts and completes all duties positively and without conflict; abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner, consistent with the organization’s values; accesses and accurately maintains electronic and paper medical records; responds to overhead pages; cooperates, helps others, and improves the performance of the unit; completes all mandatory unit, educational and hospital requirements; adheres to current Infection Control and Safety Standards; adheres to hospital and departmental policies and procedures, including those related to confidentiality; regular and prompt attendance; ability to work schedule as defined and additional hours as required; related duties as required.
Qualifications:Bachelor’s degree in nursing or allied health from an accredited institution as approved and accepted by the University of South Alabama, three years of medical data analysis experience, and current licensure with the state of Alabama in clinical field.
Preference will be given to those applicants with a bachelor’s degree in nursing. Master’s degree in nursing is preferred. Knowledge of ICD and CPT coding systems is preferred. Medical record auditing experience is preferred.
