JOB SUMMARY

Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. Assist with overseeing department workflow and metrics. Create reports used to make strategic decisions. Educate and train 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, by improving the quality of the physicians’ clinical documentation.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

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 sevirty of illes; and (b) initiate a review worksheet.
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate physician queries regarding missing, unclear or confliting health record documentation by requesting and obtaining additional documentation within the heatlh record, as necessary.
• Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.

Lead Responsibilities:

• Provides daily support/mentoring/training to new hires as well as existing staff.
• Provides assistance in managing escalated issues and special projects as needed to supervisors and managers. CDI staff coverage
• Performs concurrent and retrospective CDI audits
• Provides CDI support/mentoring/training to Physicans and hospital leadership as needed.
• Completion of scrubbing and submitting monthly data to vendor
• Enters facility specific data to dashboards
• Resolves problems, concerns and reports issues with Operations Supervisor, Manager or Director.

Professional Development:

• Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding.
• Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding.
• Quarterly review of AHA Coding Clinic.
• Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.

CDI:

• Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution

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 accommodations 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 work flow
• 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 maintain 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 teach others to follow them
• 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
• Facility schedule review to ensure units needs covered per P&P
• CDI staff coverage
• 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: Three (3) or more years experience in CDI
• Graduate from a Nursing program, BSN, 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, 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 accommodations 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 & mouse to perform CDI functions
• 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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

• Must be able to travel regionallyas 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 our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!