Clinical Documentation Coordinator
Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.
Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services. This Coordinator is also responsible for coding and abstracting all outpatient records including emergency room and ambulatory surgery visits.
Essential Job Functions:
- Able to utilize inpatient admission criteria while completing thorough review of patient records within 24-48 hours of admissions to evaluate documentation to assign the principal diagnosis, all pertinent secondary diagnoses including complications and comorbidities, and procedures for accurate working DRG assignment.
- Conducts follow-up reviews of inpatient records every 2-3 days to support working or final DRG assignment upon patient discharge, as necessary
- Facilitates appropriateness of clinical documentation through extensive medical record review and positive working relationships with physicians and other caregivers through the use of written queries and effective verbal discussions. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality.
- Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Serves as a resource to physicians, other clinical staff, and administration on documentation requirements and reporting and reimbursement issues identified through daily and retrospective reviews.
- Codes and abstracts all outpatient records including emergency room and ambulatory surgery visits using standard ICD-10-CM and CPT coding guidelines.
- Reviews E/M levels for appropriateness
- Enters proper ER, OBS and MTR changes
- Retrieves records as needing for coding review
- All other duties as assigned.
- Minimum: Associates or Bachelor's Degree in Nursing or Health Information Management.
- Current Texas RN or LVN License, or RHIT/RHIA with CCS Credentials preferred.
- Minimum of five (5) years of clinical experience in an acute care setting; critical care, medical/surgical or Emergency Department nursing preferred. Or, minimum of three (3) years of coding experience in an acute care setting.
- Excellent verbal and communication skills with great comfort in working with Physicians or their extenders.
- Knowledge of the DRG structure, ICD-9-CM, CPT Coding Guidelines and regulatory requirements preferred but in-depth training is available. Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment.
Required Knowledge, Skills, and Abilities/Working Conditions:
- Knowledge of care delivery documentation systems and related medical record documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Excellent written and verbal communication skills.
- Excellent critical thinking skills.
- Demonstrated positive physician relationships in the past and has the ability to maintain those going forward.
- Working knowledge of inpatient admission criteria.
- Ability to work independently in a time-oriented environment.
- Computer literacy and familiarity with the operation of basic office equipment.
- Collegial personality traits to facilitate ongoing physician communication.
- Ability to stand and walk for periods of time is required in the performance of job responsibilities.
- Working knowledge of Medicare reimbursement system and coding structures required.
- Medical, Dental, Vision, Insurance
- Income Protection
- Retirement Savings,
- Flexible Account Spending
Healthcare Professionals have a unique opportunity to affect lives for the better every day. At Doctors Hospital of Laredo, we are looking for qualified, passionate, and dedicated Registered Nurses.