Clinical Doc Improv Spec 2

Baylor Scott & White Health; Santa Fe (NM); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Immediate eligibility for health and w

401(k) savings plan with dollar-for-d

Tuition Reimbursement

PTO accrual beginning Day 1

Job summary

Baylor Scott & White Health in Santa Fe, NM seeks a Clinical Documentation Specialist who will perform patient record reviews to ensure complete and accurate documentation supporting hospitalization and treatment. You will query physicians to clarify unclear documentation and work with HIM coders to optimize DRG assignments.

The role requires a Bachelor’s degree in nursing or health information management, RN or RHIA certification, and CDI/medical-record review experience with ICD-10 knowledge.

Qualifications

• Bachelor’s degree in nursing or Health Information Management or Health Informatics.
• RN or RHIA certification required; one of CCS, CCDS, CCDOSCP, CCDS-O, CDIP or CPC preferred.
• 4 years nursing experience or 4 years medical record review experience in inpatient coding/auditing or CDI.

Responsibilities

• Facilitates accurate, timely, and complete documentation in patient records.
• Performs review of records to ensure complete documentation and updates DRG when appropriate.
• Collaborates with clinicians and HIM coders to improve documentation and coding opportunities.
• Develops and provides ongoing education about documentation opportunities to practitioners and teams.

Skills

Documentation review

DRG coding

Query physicians

Interdisciplinary collaboration

Education

Bachelor's degree in Nursing/Health Information Management/Health Informatics

Job description

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).

As a health care system committed to improving the health of those we serve, we are asking our employees to model the same behaviours that we promote to our patients. As of January 1, 2012, Baylor Scott & White Health no longer hires individuals who use nicotine products. We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.