HIM Clinical Documentation Specialist NEW Position Available In Philadelphia, Pennsylvania

HIM Clinical Documentation Specialist

Job ID:

269486

Category:

Health Information Management/Coding

Work Type:

FT

Location:

Philadelphia, PA, United States

Work Schedule:

8hr Days
Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and givefort and reassurance. Our employees shape our future each day. Are you living your life’s work?

Entity:

Corporate

Department:

Corp HIM CDI

Location:

Hospital of the University of Pennsylvania- 3400 Spruce St

Hours:

8hr Days

Summary:

The Clinical Documentation Specialist will be responsible for supporting ananization-wide system for improving clinical documentation in the medical record by prompting physicians and other clinicians forplete and accurate documentation. The CD Specialist will utilize presentation, general instruction, and apliant query discussion to instruct the clinical teams in appropriate documentation as suggested by CMS coding guidelines and to ensure that the clinical chart is the true and reflective document of the patient, their related prioritized diagnostic portrait, severity of illness, and treatment related. Working under the leadership and moderate supervision of the Corporate Manager of Clinical Documentation and in close concert with both the clinical care teams and the Corporate HIM teams, the Clinical Documentation Specialist will educate and utilizepliant questions and tools toward aplete, reflective record. They will also analyze trends and offer direction to primary care staff w regard to changes in coding practices and noted trends noted in team documentation requiring clarity and/or specification to reflect truth in diagnostic reflection.

Responsibilities:

Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines
Provide clinical care teams with ongoing education and training on current trends in documentation and coding
Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department
Enter clinical review data and related anticipated follow-up in

EPIC PENN

Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG
Generatepliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity
Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above notedpliant query system
Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes
Assign a working MS-DRG upon initial admission review, andmunicate with Physician or designee requesting appropriate documentation
Ongoing concurrent chart review, identification ofplications and co-morbidities, collaboration with team regarding improving documentation
Maintain strict HIPPApliance and confidentiality in reference to all information reviewed and/or discussed
Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation
Proficient in negotiatingplex systems to effect positive change
Ability to interpret, adapt, and guidelines and procedures
Ability to analyzeplex clinical scenarios and critical thinking. Extensive knowledge of reimbursement systems
Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
Serve as a resource on DRG issues

Credentials:

RHIA or RN (Preferred)
CCDS or CDIP or RN (Preferred)

Education or Equivalent Experience:

Bachelor of Arts or Science (Required)
And 3+ years healthcare experience
Master of Arts or Science (Preferred)
Clinical experience with knowledge of Medicare reimbursement system & coding structures (Preferred)
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer aprehensivepensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged andmitted to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life’s Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.