Document Reviewer

University of Miami; Hialeah (FL); On-site; USD 50,000 - 90,000; Full time

Job summary

Join a forward-thinking institution as a Clinical Documentation Specialist, where your expertise in ICD-10 coding will play a crucial role in enhancing the accuracy of medical records. In this dynamic position, you'll collaborate with healthcare providers to ensure compliance with coding guidelines while optimizing documentation quality. Your contributions will directly impact patient care and research initiatives. This role offers a unique opportunity to grow in a supportive environment that values continuous education and professional development. If you're ready to make a meaningful difference in healthcare, this is the perfect opportunity for you.

Benefits

Medical Insurance

Dental Insurance

Tuition Remission

Flexible Work Hours

Continuing Education Opportunities

Qualifications

• 5+ years of inpatient coding experience with ICD-10-CM/PCS.
• Certified Coding Specialist (CCS) or similar certification preferred.

Responsibilities

• Assign and sequence accurate ICD-10 codes for inpatient records.
• Collaborate with providers to ensure accurate documentation.

Skills

ICD-10-CM coding

ICD-10-PCS coding

Clinical Documentation Improvement (CDI)

Medical Terminology

Health Information Management

Computer-Assisted Coding (CAC)

MS Office Suite

Critical Thinking

Education

Bachelor’s degree in Business Administration

Bachelor’s degree in Health Care Administration

Bachelor’s degree in Health Information Management

Tools

Electronic Medical Record (EMR) software

Encoder software

Computer-Assisted Coding (CAC) tools

Job description

Clinical Documentation Specialist 2 - Concurrent Quality Reviewer - Full Time

Location: Hialeah, FL / Miami, FL

Time Type: Full time

Posted: 30+ Days Ago

Job Requisition ID: R100079362

The Concurrent Quality Reviewer of our hospital reviews documentation in the electronic medical record (EMR) and ensures that accurate assignment and sequencing of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes in accordance with national coding guidelines. The primary focus of this role is to capture all encounter-specific diagnoses, procedures, and documented conditions for accurate reporting and research purposes. The goal is to achieve concurrent/real-time assignment of ICD-10 codes and DRGs. This will be achieved by optimizing accuracy of documentation by collaborating with the providers, CDIs, Coders, Quality, and other relevant multidisciplinary teams. The concurrent inpatient quality reviewer will assign a working DRG, as well as capture and ensure accurate POA assignment, severity of illness, mortality risks, SDOH codes, etc. This position will assist with identifying trends that will be used to develop and provide educational training for CDI teams, providers, etc.

Responsibilities:

• Uphold compliance by assigning and sequencing accurate ICD 10 codes to inpatient medical records as per guidelines, demonstrating behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
• Determine and assign the principal diagnosis and all significant secondary ICD-10-CM diagnoses as well as Present on Admission (POA) indicator and ICD-10-PCS procedure codes, using official coding guidelines.
• Validate the accuracy of codes assigned by the computer-assisted coding software, recognizing inappropriate application of clinical coding regulations/guidelines, and revising the codes assigned based on expert subject matter knowledge and provider documentation.
• Literacy and proficiency in computer technology, particularly related to health information and coding applications utilized for daily job performance, are essential.
• Strong ability to analyze clinical documentation to ensure codes reported are clearly and consistently supported by the health record.
• Examine and ensure that the MS-DRG, APR-DRG, SOI, and ROM of each inpatient encounter is compatible and compliantly optimized.
• Request clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record regarding a significant reportable condition or procedure.
• Abstract relevant information accurately and completely into the computer-assisted coding application, including but not limited to present on admission (POA) indicators.
• Verify and revise according to documentation in the medical record the correct discharge disposition of encounters coded.
• Confirm the admission status ordered by the physician in the medical record documentation and the registration status of the encounter are compatible with orders.
• Communicate professionally identified discrepancies, documentation issues, denial management issues, and coding concerns in the medical record to the appropriate department and/or leader.
• Stay up to date with regulatory changes by completing all mandatory educational accountabilities in a timely manner.
• Maintain coding quality and productivity as per departmental standards.
• Attend department meetings and other inpatient conferences and seminars as scheduled.
• Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines.
• Maintain coding accuracy and productivity standards of ≥ 95%.
• Attend educational meetings and seminars to maintain certification and continuing education requirements.
• Prepare ad-hoc reports as requested by senior management.
• Develop, mentor, educate, and provide feedback to providers, CDI, and others as applicable in coding and ICD-10/DRG code assignment.
• Adhere to University and unit-level policies and procedures and safeguard University assets.

Minimum Requirements:

Education: Bachelor’s degree in a related field such as Business Administration, Health Care Administration, or Health Information Management is highly preferred.

Certification and Licensing: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and/or Certified Inpatient Coder (CIC) highly desired.

Experience: Minimum 5 years of coding in an inpatient hospital setting. Must have ICD-10-CM/PCS medical coding experience. Strong knowledge of anatomy and physiology, medical terminology, and disease processes. Advanced technical skills for use of MS Office (Excel, Word, Outlook, and PowerPoint). Experience with CAC is a must.

Knowledge, Skills, and Aptitudes:

• Skill in completing assignments accurately and with attention to detail.
• Ability to analyze, organize, and prioritize workload while consistently meeting ≥ 95% productivity and accuracy standards.
• Understanding of and adherence to the Health Insurance Portability and Accountability Act (HIPAA).
• Commitment to the University of Miami Health System policies and procedures.
• Must stay up to date with continuing education requirements to maintain credentials.
• Ability to work independently and/or in a collaborative environment.
• Strong background in the use of encoder, computer-assisted coding, and EMR software applications.
• Efficient communication skills - interpersonal, verbal, and written.
• Strong organizational and analytical skills.
• Critical thinking skills and ability to interpret, assess, and evaluate provider documentation.
• Proficient with Microsoft Office applications.
• Ability to sit for long periods of time.
• Capable of working in a 100% remote environment with little supervision, while also staying focused on assigned tasks.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission, and more.

The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.