Trinity Health Clinical Documentation & Coding Specialist in Ft. Lauderdale, Florida
Holy Cross Hospital in Fort Lauderdale, Florida is a full-service, non-profit Catholic hospital, sponsored by the Sisters of Mercy and a member of Trinity Health.
Clinical Documentation Medical Record Review
- Utilizes paper or electronic tools and reports to identify and prioritize case reviews, follow-up reviews and outstanding queries.
- Utilizes critical thinking skills to perform concurrent review of clinical documentation in the medical record.
- Analyzes the patient s current clinical status, treatment plan and past medical history to identify potential gaps in physician documentation.
- Identifies the principal diagnosis and all secondary conditions, co-morbidities, complications and procedures that have been documented in the medical record.
- Evaluates anchor visit for each diagnosis that could potentially affect risk score calculation.
- Queries the physician, mid-level clinicians and other clinicians for clarification and to obtain accurate and complete documentation as needed, based on current clinical findings, prescribed treatment, medical interventions and/or procedures.
- Follow commercial and governmental coding regulations as determined by payer
- Adheres to AHIMA guidelines for effective, compliant query writing.
- Regular queries to Claims and Clinical data and appropriate follow-up interventions
- Applies knowledge/skills regarding coding conventions, coding guidelines and coding clinics when reviewing the medical record.
- Adheres to the Clinical Documentation programs established work flow and processes.
- Performs retrospective medical record reviews, as requested.
- Access claims and clinical data to identify high and low network performers
- Focus on commercial products, may assist with Medicare Advantage preparation and planning
- Interact with IT teams from each participating organization to understand and identify EHR capabilities and coding tools for HCC and MRA coding
Interdisciplinary Communication & Relationships
- Works collaboratively with the coding professionals to obtain documentation of diagnoses, co-morbidities and procedures which results in a complete and accurate reflection of the patients clinical status and care.
- Consults with coding professionals as needed, for clarification regarding coding convention and guidelines.
- Works collaboratively with the Medical Director when escalation of cases is required, and to develop and implement ongoing physician education programs.
- Collaborates with physicians, mid-level residents/interns, mid-level clinicians and other clinicians to accurately identify principal diagnosis options, secondary diagnoses and procedures.
- Serves as a resource to physicians, mid-level clinicians and other clinicians regarding clinical documentation, severity of illness and risk of mortality.
- Approaches and responds to conflict in a constructive manner, with a focus on problem solving for a collaborative solution/resolution.
- Provides formal and informal feedback and training to physicians, mid-level clinicians and other clinicians with respect to clinical documentation excellence and the impact of documentation on coding accuracy, healthcare profiling and correct reimbursement.
- Work collaboratively with subnetwork documentation and coding specialists
Data Management and Reconciliation Process
- Demonstrates competency with utilization of all necessary software and information systems necessary to conduct clinical documentation activities.
- Self-monitors performance data though weekly reports.
- Identifies opportunities during reconciliation process for second-level review and follows up with coding professionals to make sure appropriate documentation is present for accurate coding.
- Generate and present appropriate reports as requested
- Interprets data monitoring reports and identifies areas of focus for documentation improvement through analysis of monthly data.
- Maintains professional integrity and confidentiality of information in accordance with applicable policies, procedures, state and federal requirements.
- Assist with departmental policy review, revision and development. Assist with identifying workflow and modification of same to improve efficiencies.
- Associates Degree required.
- BSN preferred with 5 years of acute care nursing experience, or, in lieu of a nursing degree, a Bachelor's degree in Health Information Management or a related field and five 3 to 5 years of inpatient coding experience; Or Foreign Medical Graduate with 3 to 5 years of experience generally obtained from Clinical rounding, clinical shadowing or previously worked as Clinical Documentation Specialist.
- Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred; Experience in delivering education to diverse group of people and able to understand and deliver clinical terms with physicians and unit nurses; Experience with databases, spreadsheet software and presentation software preferred; Experience working with EPIC, Optum and CDIS. Able to understand and analyze reports.
Job Number: 00058803
Location: Ft. Lauderdale, FL
Organization Name: Holy Cross Hospital
Facility: HCHFL - Holy Cross Hospital
Employment Type: Full time
Shift: Day Shift