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Job description
Job Summary
JOB SUMMARY
Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Assists with overseeing department workflow and metrics. Educates and trains department staff. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
1. Record Review:
Completes initial medical records 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 MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review in host system.
Conducts follow-up reviews of patients every 1-3 days to support and update the working MS-DRG, as necessary.
Formulates physician queries due to missing, unclear or conflicting documentation as necessary.
Collaborates with providers, case managers, nursing staff and other ancillary staff to assist in resolving physician queries prior to discharge.
2. Lead Responsibilities:
Provides daily support/mentoring/training to new CDI hires as well as existing CDI staff.
Provides assistance in managing escalated issues and special projects as needed to supervisors and managers. CDI staff coverage as necessary
Performs concurrent and/or retrospective CDI reviews as necessary
Provides CDI support/mentoring/training to Physicians and hospital leadership as necessary.
Enters facility specific data to dashboards as necessary
3. Resolves problems, concerns and reports issues with Operations to Supervisor,Manager or Director. Assists with orientation of new CDI Staff
4. Professional Development:
Completes yearly required learnshares
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD coding.
Attends mandatory coding sessions on annual basis (IPPS and ICD updates) for inpatient coding.
Quarterly review of AHA Coding Clinic.
Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
5. Provider Engagement: Conducts provider rounding, provides education, and communicates with providers on documentation and physician query opportunities as appropriate for follow up and resolution.
6. Other duties as assigned
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Must display teamwork and commitment while performing daily duties
Must demonstrate initiative and discipline in time management and medical record review
CDI Subject Matter Expert with Advanced knowledge of Medicare Part A and familiar with Medicare Part B
Intermediate knowledge of disease pathophysiology and drug utilization
Intermediate knowledge of MS-DRG classification and reimbursement structures
Critical thinking, problem solving and deductive reasoning skills
Effective written and verbal communication skills
Knowledge of coding compliance and regulatory standards
Excellent organizational skills for initiation and maintenance of efficient workflow
Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment.
Understand and communicate documentation strategies
Recognize opportunities for documentation improvement
Formulate clinically, compliant credible queries
Ability to comply with an auditing and monitoring program as a means to measure query process
Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
Must be able to resolve issues effectively and provide recommendations and solutions
Effectively explain processes and educate others
CDS SME with ongoing education with physicians and facility leaders
CDI facility representation for hospital and physician meetings
Local facility mentorship for CDI team support and effectiveness
CDI staff coverage as necessary
Gathering additional data as needed for supervisor, manager and director
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
Preferred: Two (2) or more years’ experience in CDI
Graduate from a Nursing program, RN, BSN, Medical Doctor, Foreign Medical Doctor, and/or graduate of Health Information Management RHIT, RHIA preferred
Preferred: Two (2) years’ experience with either HIM/Coding or Case Management experience.
CERTIFICATES, LICENSES, REGISTRATIONS
Required: RN, Medical Doctor, Foreign Medical Doctor, or RHIT, RHIA, and/or CCS
Preferred: CDIP or CCDS
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Ability to sit for extended periods of time
Must be able to efficiently use computer keyboard and mouse
Good visual acuity
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
OTHER
Must be able to travelas needed, not to exceed 10%
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help
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Worksite address
frisco, TX, 75034, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.