Clinical Documentation Specialist II

Abrazo Health

Phoenix (AZ)

On-site

USD 49,000 - 77,000

Full time

9 days ago

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Benefits offered by this job

Medical, dental, vision, and life保险

401(k) retirement savings plan with-em

Generous paid time off

Career development opportunities

Health savings accounts, healthcare &/

Employee Assistance program

Pet insurance (voluntary)

Job summary

Abrazo Community Health Network Hospital in Phoenix, AZ is seeking a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation reflecting illness severity and mortality risk. You will work with physicians, case management, nursing, and coding staff to review inpatient records, educate teams on documentation, and support accurate DRG assignments.

Requires nursing background (RN) or RHIA/RHIT/CCS/CIC, 2–5 years CDS experience, and strong communication and

Qualifications

Knowledge of care delivery documentation systems and related medical record documents.
Detailed knowledge of MSDRGs and OIG work plan as it relates to correct coding.
Excellent written and verbal communication and interpersonal skills.
Ability to work independently in a time-oriented environment.

Responsibilities

Initiates and performs concurrent documentation review of inpatient records.
Educates physicians and clinicians on complete documentation for accurate coding.
Ensures coding accuracy and MDG alignment through queries and education.
Performs DRG reconciliation and monitors query outcomes.
Collaborates with physicians, case management, nursing, and coding staff.

Skills

Care documentation systems

MSDRGs knowledge

Communication skills

Interpersonal skills

Independent work

Critical thinking

Education

RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP

Job description

Overview

Abrazo Community Health Network Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Abrazo Community Health Network, We Understand That Our Greatest Asset Is Our Dedicated Team Of Professionals. That's Why We Offer More Than a Job - We Provide a Comprehensive Benefit Package That Prioritizes Your Health, Professional Development, And Work-life Balance. The Available Plans And Programs Include

Medical, dental, vision, and life insurance
401(k) retirement savings plan with employer match
Generous paid time off
Career development and continuing education opportunities
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Job Summary

Position Summary

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

Responsibilities

Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined.
Performs ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities.
Supports the Coding Department through communicating with physicians regarding open queries; acts as liaison between coding and physicians.
Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.
Collaborates with the Physician Advisor in identifying patterns of physician documentation issues,
utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings
Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation.
Participates in orientation, precepting, and mentoring of new team members.
Other related job tasks or responsibilities as assigned

Qualifications

Special Skills
- Knowledge of care delivery documentation systems and related medical record documents.
- Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
- Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff.
- Computer skills and familiarity with basic office equipment required.
- Ability to work independently in a time oriented environment.
- Self-directed, motivated, and possess a positive attitude.
Minimum Requirements
- Education: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
- Experience: 2-5 years CDS experience
- Licensure/Certifications: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP

Organization Description

Tenet's hospital operations segment includes 52 acute care and specialty hospitals in nine states, as well as other facilities such as primary and specialty care clinics, diagnostic imaging centers, micro-hospitals and off-campus emergency departments. Our hospitals are well known for delivering excellent medical care and offering a complete range of services tailored to the needs of each community we serve. From preventative and diagnostic services to expertise in some of the world’s leading technologies, we work with multidisciplinary teams of physicians and healthcare professionals dedicated to the good health and well-being of our neighbors. Tenet also offers opportunities to work at the corporate level in Dallas, TX and in the markets we serve. Corporate and executive positions support the mission of the enterprise.

Employment practices will not be influenced or affected by an applicant's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.

2603019939

$35.85 - $55.55 hourly **Individual wages are determined based upon a number of factors including, but not limited to, an individual's qualifications and experience,

Special Skills
- Knowledge of care delivery documentation systems and related medical record documents.
- Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment.
- Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff.
- Computer skills and familiarity with basic office equipment required.
- Ability to work independently in a time oriented environment.
- Self-directed, motivated, and possess a positive attitude.
Minimum Requirements
- Education: Graduate of an accredited school of nursing, AHIMA accredited school, United States or international school of medicine
- Experience: 2-5 years CDS experience
- Licensure/Certifications: One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP

Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined.
Performs ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities.
Supports the Coding Department through communicating with physicians regarding open queries; acts as liaison between coding and physicians.
Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.
Collaborates with the Physician Advisor in identifying patterns of physician documentation issues,
utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings
Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation.
Participates in orientation, precepting, and mentoring of new team members.
Other related job tasks or responsibilities as assigned