Clinical Doc Improv Spec 2
Performs patient record reviews to ensure complete, accurate, and timely documentation of all conditions supporting hospitalization and treatment.
- Pay
- Not posted
- Unit and setting
- Hospital
- License
- RN license Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
- Term
- Permanent
Do you qualify?
- License
- Registered Nurse (RN) or Registered Health Information Administrator (RHIA) Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
- Certification
- CCS, CCDS, CCDOSCP, CCDS-O, CDIP, or CPC certification
- Education
- Bachelor's degree in nursing, Health Information Management, or Health Informatics Must have a Bachelor's degree in nursing or Health Information Management or Health Informatics.
- Experience
- 4 years of nursing experience or a combination of inpatient coding with at least 2 years of CDI experience Nursing: Must have 4 years of nursing experience or a combination of inpatient coding with at least 2 years of CDI experience.
- Experience
- 4 years of medical record review experience in inpatient coding/auditing, Quality, Case Management, or CDI for HIM candidates HIM: 4 years of medical record review experience in inpatient coding/auditing or Quality, or Case Management, or CDI.
- Experience
- 4 Years of Experience EXPERIENCE - 4 Years of Experience
- Experience
- at least 2 years of CDI experience if combining with inpatient coding
- Also asks
- knowledge of ICD-10, Complications/Comorbid Conditions, and how each sets the final DRG, SOI, and ROM Know ICD-10, Complications/Comorbid Conditions, and how each sets the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
What it pays
- Tuition assistance
- Offered
- Eligibility
- immediate eligibility for health and welfare benefits
- Eligibility
- PTO accrual beginning Day 1
Benefits
- BenefitsImmediate eligibility for health and welfare benefitsImmediate eligibility for health and welfare benefits
- Benefits401(k) savings plan with dollar-for-dollar match up to 5%401(k) savings plan with dollar-for-dollar match up to 5%
- BenefitsTuition ReimbursementTuition Reimbursement
- BenefitsPTO accrual beginning Day 1PTO accrual beginning Day 1
- health and welfare benefits
Pay isn’t listed.
The role and schedule
- Day to day
- facilitate accurate, timely, and complete medical documentation in patient records Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
- Day to day
- review patient records to establish complete documentation and update working DRG when appropriate
- Day to day
- obtain documentation supporting severity of illness, risk of mortality, and complexity of care
- Day to day
- recommend queries regarding missing, unclear, or conflicting documentation and escalate non-responses
- Day to day
- collaborate with HIM coders, CDI specialists, and interdisciplinary teams to reconcile documentation and coding opportunities
- Day to day
- collaborate with interdisciplinary teams to validate accurate DRG assignments Collaboratively works with interdisciplinary teams to validate accurate DRG assignments.
- Day to day
- develop and provide ongoing documentation education to practitioners, coders, and CDI specialists
- Day to day
- formulate and analyze data to improve documentation practices
The workplace
Ask Mira
Your fit
Questions to ask
- Can you walk me through base pay range and differentials?
- What should I expect for shifts, weekly hours, weekend, holiday, call, and rotation?
- What orientation, preceptor time, and ongoing unit support are included?
- How are patient load, floating, and staffing support handled day to day?
Original listing
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About Us
Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.
Our Core Values are
- We serve faithfully by doing what's right with a joyful heart.
- We never settle by constantly striving for better.
- We are in it together by supporting one another and those we serve.
- We make an impact by taking initiative and delivering exceptional experience.
Benefits
Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level.
Job Summary
Performs patient record reviews to ensure complete, accurate, and timely documentation of all conditions supporting hospitalization and treatment. Present queries to physicians to clarify unclear or incomplete documentation. Must know ICD-10, Complications/Comorbid Conditions, and their role in the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
Essential Functions of the Role
- Facilitates accurate, timely, and complete documentation of medical conditions and treatment in patient records.
- Performs review of record to establish complete, accurate documentation of patient condition and treatment. When appropriate, update working DRG.
- Promotes and obtains documentation for clinical conditions or procedures. This supports the severity of illness, risk of mortality, and complexity of care through interaction with practitioners.
- Demonstrates the ability to recommend proficient queries to practitioners or support staff about missing, unclear, or conflicting health record documentation. Escalates provider non-responses or inappropriate responses for reconciliation.
- Collaborates with Health Information Management coders and Clinical Documentation Improvement Specialists. Reconciles potential documentation and coding opportunities, including examining working versus final coded DRG. Works with interdisciplinary teams, including physicians, mid-level providers, nurses, Patient Safety, and Health Care Improvement.
- Collaboratively works with interdisciplinary teams to validate accurate DRG assignments.
- Develops and provides ongoing education about documentation opportunities to practitioners, Health Information Management Coders, and Clinical Documentation Improvement Specialists. Promotes related education to allied health professionals, Administration, Utilization Review, and Comprehensive Care. Focuses on documentation's effect on SOI, ROM, CMI, reimbursement, and data reporting.
- Formulates, interprets, and examines data to improve documentation practices. The focus could include DRG impact, SOI/ROM, or physician profiles.
Key Success Factors
- Must have a Bachelor's degree in nursing or Health Information Management or Health Informatics.
- Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).
- Requires one of these
certifications
Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), BSW code (CCDOSCP), Certified Clinical Documentation Specialist Outpatient (CCDS-O), Certified Documentation Improvement Practitioner (CDIP), or Certified Professional Coder (CPC).
- Nursing: Must have 4 years of nursing experience or a combination of inpatient coding with at least 2 years of CDI experience.
- HIM: 4 years of medical record review experience in inpatient coding/auditing or Quality, or Case Management, or CDI.
- Know ICD-10, Complications/Comorbid Conditions, and how each sets the final Diagnosis Related Group, Severity of Illness, and Risk of Mortality.
Belonging Statement
We believe that all people should feel welcomed, valued and supported.
Qualifications
- EDUCATION - Bachelor's
- EXPERIENCE - 4 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Cert Cln Documentation Spec (CCDOCSP), Cert Clin Doc Spec Outpatient (CCDS-O), Cert Coding Specialist (CCS), Cert Doc Improv Practitioner (CDIP), Cert Professional Coder (CPC): Requires one certification.
Cert Cln Documentation Spec (CCDS) BSW code(CCDOSCP) or
Cert Cln Doc Spec Outpatient (CCDS-O) or
Cert Coding Specialist (CCS) or
Cert Doc Improv Practitioner (CDIP) or
Cert Professional Coder (CPC).
Reg Health Info Administrator (RHIA), Registered Nurse (RN): Must be a Registered Nurse (RN) or Registered Health Information Administrator (RHIA).