A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
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Comprehensive health benefits that start day 1 Student Loan Repayment Assistance & Reimbursement Programs Family-focused benefits Wellness incentives Ongoing mentorship, development, leadership programs And more Description
JOB DESCRIPTION
Reviews inpatient medical records for select payer populations post-discharge and pre-bill; audits the accuracy and completeness of diagnosis and procedure coding, DRG assignment, and abstracted data POA, Discharge Disposition. Reviews discrepancies between the Clinical Documentation Specialist (CDS) DRG and the Coder DRG. Reviews non-CC/MCC records to determine if record was miscoded or if additional documentation is needed. Works with Coders and CDSs to draft and initiate physician queries. Performs reviews in a timely manner to maintain DNFB target of 4 days. Provides Coding development with coordination of educational and training programs regarding technical coding and clinical topics for the coding staff. Coordinates remediation when required. Coordinates with the Coding leadership, Quality nurses and the CDS team to educate physicians, nursing, and other clinical staff to improve documentation. Review's DRG Reassignment letters and assists in formulating Appeal letters
Minimum Required Qualifications:
Education:
High school diploma
Experience:
Minimum five (5) years experience with coding ICD-10 in an acute care setting. Previous experience in performing DRG coding audits.
Certification:
Certified Coding Specialist (CCS) certification.
Skills:
1. Possesses knowledge of DRG and grouping methodologies (MS DRG's and AP DRG's); in particular what diagnoses / procedures impact DRG assignment. 2. Basic computer skills in word processing and spreadsheet utilization. 3. Excellent interpersonal skills to develop relationships necessary to facilitate and educate. 4. Excellent prioritization and organizational skills.
Preferred Qualifications:
Education:
Bachelor's degree in related field
Certification:
RHIA/RHIT. PHYSICAL REQUIREMENTS
(Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS
Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock , Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks. Additional Details Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.
