Clinical Documentation Specialist
Location: Bozeman Montana
Description: Bozeman Deaconess Hospital is presently looking of Clinical Documentation Specialist right now, this position will be placed in Montana. More details about this position opportunity please give attention to these descriptions. Required
Graduate of an approved school of nursing
Three (3) years of medical/surgical nursing experience
Current Montana license as an! Registered Nurse
Preferred
BSN
A
t least one year of Bozeman Deaconess Hospital experience, preferred
CCS, RHIT, RHIA certification
3 - 5 years coding experience in an acute care setting and auditing experience.
Job Summary
The Clinical Documentation Specialist (CDS) is responsible for the overall improvement of quality and completeness of Medical Record Documentation.
The CDS must have a strong clinical background in a variety of settings.
The CDS is responsible for training and educating appropriate medical care team members on AHA Coding Clinic guidelines and ensuring that clinical information utilized in profiling and reporting is complete and accurate.
The CDS will serve as a resource on documentation and coding issues for appropriate team members and must work collaboratively with other departments, (i.e. case management).
Will be responsible for quarterly repo! rts regarding improvements in clinical documentation and impac! t on revenue cycle.
Responsible for ensuring proper working DRG assignment for patients admitted to Bozeman Deaconess Hospital.
Essential Job Functions
Appropriately
identify and screen the medical record of all Medicare admissions within 24-48 hours of admission, assign a working principal diagnosis, secondary principal diagnoses, procedures, DRG and problem list.
I
dentify query opportunities and appropriately query (verbal/written) the physician to clarify any diagnosis, and any treatments without related documentation.
Additional Job Functions:
1.
Maintain all worksheets and query forms.
2.
Run quarterly reports and other reports as requested
3.
Schedule meetings as necessary/requested to present and discuss documentation issues.
4.
As time allows, assist inpatient coding.
Accurately assigns diagnosis, procedure codes and DRGâ! €™s to inpatient, day surgery, observation, outpatient, and emergency room records utilizing appropriate coding guidelines.
Coding is consistent with applicable regulations, including the official coding promulgated by CMS, the American Hospital Association, American Health Information Management Association and compliance policies.
Communicates with physicians/physician offices to clarify diagnosis or procedures for appropriate code assignment when documentation is unclear.
Meets established accuracy rate of 95% or higher.
5.
Abstracts specified criteria for each inpatient, day surgery, observation, and emergency room encounter for reporting purposes and data elements for quality assurance.
Validates all essential data elements that are entered by Admitting against the patients’ medical record when abstracting (i.e. disposition, patient status, patient type, etc.)
Any discrepancies are communicated back to Ad! mitting for corrections.
Coders are key individuals that may c! atch lost charges that have not been entered by various departments.
This information is communicated to the supervisor of the responsible department, and Managers of the Medical Records Department, Patient Financial Services and/or Case Management.
Reports coding issues to Manager of the Medical Records Department.
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to Bozeman Deaconess Hospital.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Thu, 27 Jun 2013 20:56:40 GMT