Job Description Summary
Under the general supervision of the Manager of Clinical Documentation, will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness. The documentation specialist is on–site and available five (5) days a week.
Job Description
Essential Fucntions
1. Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness
a. Produce worklists from Meditech daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission
a. Present overview of program to new physicians and other care providers at orientation
a. Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness
a. Identifies trends or potential problems and assists in developing action plans to address.
6. Participates in organizational surveys that evaluate staff perception of safety.
7. Seeks and participates in educational opportunities to improve job skills and program.
8. Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.
9. Identifies annually at least one implementable idea to improve patient, staff or environmental safety.
11. Understands roles/responsibilities during hospital codes.
12. Adheres to respiratory etiquette guidelines.
a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
Excellent communication and critical thinking skills. Demonstrates leadership qualities such as the ability to motivate, teach, and facilitate individuals and groups on reaching the objectives of the program. Working knowledge of Medicare and Blue Cross inpatient reimbursement and coding structures is desired. Knowledge of care delivery documentation systems and related medical record documents desired. Knowledge of age-specific needs and the elements of disease processes and related procedures preferred. Self-motivated, innovative individual who has the ability to work in a time oriented environment. Prefer experience interacting with physicians and concurrent review with clinical records. Basic personal computer skills required.
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