Work Type: Active - Benefit Eligible and Accrues Time Off Exempt: Yes
Work Schedule: Monday - Friday Work Hours per Biweekly Pay Period: 80
Location: Suntrust, US:FL:Lakeland
Summary: The Clinical Documentation Specialist reports reports to the Manager of Coding and Clinical Documentation Improvement. Concurrently reviews patient records to improve documentation to reflect accurate severity of illness and intensity of service and communicates with physicians. Works collaboratively with HIM Director, HIM Coders, and Physician Advisor to ensure accurate coding, improve the quality of DRG-related documentation, improve risk of mortality, severity of illness and case mix index. Participates in educating physicians as needed and during the Physician Lunch & Learns. Performs other duties as assigned.
Standard Work Duties: Clinical Documentation Specialist - Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives. - Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality. - Reviews clinical issues with coding team as needed to ensure appropriate MSDRG/APR-DRG. - Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings, - Ensures the proper reflection of each patient's severity of illness, intensity of service, and risk of mortality. - Serves as a resource for physicians and educates physicians on ways to improve their documentation so it more accurately reflects intensity of services/severity of illness. - Identifies need to clarify documentation in records. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries. - Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes including Present On Admission (POA), Patient Safety Indicators (PSI), and Hospital-Acquired Conditions (HAC). Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. - Assists in developing clinical documentation training for medical staff, UR/clinical resource coordinators, nursing and coders to ensure compliance with OIG, CMS, and other applicable regulations. - Interacts with physician Advisor, HIM Director, HIM Coding staff, Compliance Officer, quality Improvement Coordinators, Department Managers, Information System staff, and Patient Financial staff on a regular basis to identify and assist in resolving documentation issues. * Stewardship - Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities. - Knows and adheres to organizational and department policies and procedures.
Qualifications & Experience
Education: Essential: Associated or Bachelors in Nursing or other healthcare related field
Essential: CCSor CDIP
Experience Essential: -2+ years acute care clinical documentation improvement experience within the past ten years. - Experience with ICD-10-CM, ICD-10- PCS, POA, HAC, and PSI coding and documentation review and DRG analysis; OR experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements. - Experience interacting with and educating medical staff and clinical support staff.
Internal Number: 6707
About Lakeland Regional Health
Lakeland Regional Health is committed to providing patient-focused, health care services while continuing to improve the quality of care to our patients, families, guests and physicians.