Clinical Documentation Integrity Specialist I, FT, Days, Remote

Prisma Health; Columbia (SC); On-site; USD 70,000 - 90,000; Full time

Job summary

Prisma Health is seeking a Clinical Documentation Integrity professional to review medical records, identify documentation opportunities, and ensure accurate coding reflecting severity of illness, risk of mortality, and length of stay.

The role involves querying providers, reconciling records, and collaborating with coding, case management and quality teams to support hospital metrics. Day shift in Columbia, SC.

Qualifications

• Associate degree or higher in Nursing, health information management, or related field.
• Two years nursing coding or related experience in acute care settings.
• In lieu of education/experience, MD/DO/PA/NP may be considered as substitution.
• RHIA/RHIT/CCS/CIC or related licensure is required or recognized.

Responsibilities

• Reviews medical records to identify documentation opportunities for accurate severity of illness, risk of mortality, length of stay and hospital quality metrics.
• Submits provider queries and reconciles discharged records to ensure precise code assignment.
• Collaborates with Coding and other departments to maintain high-quality, complete documentation.
• Stays current with coding guideline changes and compliant query policies.
• Assigns DRG for discharge planning and CDI use; acts as resource for team.

Skills

Computer skills

Communication skills

CDI knowledge (IPPS/ICD-10)

Education

Associate degree in Nursing / Health Information Management

RHIA/RHIT/CCS/CIC licensure or RN license

MD/DO/PA/NP (in lieu of education/experience)

Job description

Inspire health. Serve with compassion. Be the difference.

Job Summary

Job Profile Summary

Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment.

Job Description

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Completes the reconciliation process to ensure accurate coding reflective of patient’s severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
• Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
• Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
• Assigns a working DRG for health care team discharge planning and CDI use.
• Performs other duties as assigned

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Associate degree in Nursing, Health Information Management, or related field of study
• Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience

In Lieu Of

• In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP

Required Certifications, Registrations, Licenses

• RHIA/RHIT/CCS/CIC/or Licensure in related field of study/ Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Knowledge, Skills And Abilities

• Computer skills
• Communication skills with ability to interact with providers.
• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

Work Shift

Day (United States of America)

Location

Corporate - Columbia - Taylor at Marion

Facility

Corporate

Department

Clinical Documentation Integrity

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