Job Objective:

Under the supervision of the Director of Health Information Services or designee, is responsible for conducting clinical based retrospective reviews of inpatient medical records to evaluate and ensure the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. Identifies documentation gaps, ambiguities, or opportunities that affect diagnosis coding and DRG assignment. Brings clinical knowledge and coding expertise to ensure the medical record accurately reflects the complexity and severity of patient care. Identifies opportunities to improve documentation that impact quality program performance including patient safety indicators (PSls), hospital acquired conditions (HACs) and Medicare Star Ratings. Oversees the appeals process, reviewing records and generating supporting documentation to appeal insurance denials and RAC audits based on downgraded DRGs. Performs audit and compliance reviews to ensure CDI and coding compliance. Conducts training and education to the coders based on the results of the CDI and coding audits.

Duties and Responsibilities:

A. Auditing, Compliance and Data Quality1. Reviews and validates clinical documentation to ensure adverse events including PS ls, HACs and other quality indicators are correctly identified prior to final coding.2. Generates, evaluates, and distributes various coding and data related reports.3. Reviews CDI and Coding queries for compliance and assists with generatingqueries.4. Performs post discharge reviews for clinical documentation, and codingopportunities.5. Performs coding audits and provides feedback and education to the coders.6. Performs, participates in, and tracks internal and external audits identifying areas for improvement.7. Develops action plans, revises guidelines, and educates coders based on thenew coding rule identified, new process identified, outliers on PEPPER reports, OIG Guidance, or HCAi changes in collaboration with the Information Systems Support Coordinator-Coder 11, Coder IV, Clinical Documentation and CodingSpecialist and Coding Manager.8. Participates in hospital meetings related to clinical data quality and compliance providing data or education as required.9. Analyze DRG assignments, CC/MCC capture rates and CMI (Case Mix Index)trends. Supports accurate reporting for quality programs (e.g. PSI, HAC, mortality metrics, Medicare Star Ratings). 10. Follow-up and address discrepancies on the various coding data related reports.11. Keeps abreast of regulatory changes affecting coded information required by Centers for Medicare and Medicaid Services, HCAi, Uniform BillingRequirements, Official Coding Guidelines and others as appropriate. B. Appeal Process1. Coordinates the appeals process for RAC, external audits and insurance denials.2. In collaboration with the coding manager, develops processes to monitor high error and/or high risk clinical coded data.3. Generates supporting documentation to appeal insurance denials and RAC audits based on downgraded DRGsC. Communication1. Communicates with Coding Manager, Clinical Documentation Specialist, Coder IV, Physicians, CDIliaison, and other members of the care team to facilitate comprehensive clinical documentation to reflect treatment, decision-making and medical documentation.2. Maintains open communication with coders to ensure accuracy of DRG, and seek to resolve any incongruence.3. Work with coder and clinical documentation specialist team to ensure requirements and guidelines are Antelope Valley Medical Center compliant.4. Will work closely with physicians and members of the care team to provide continuous education on proper documentation techniques.

D. Other Duties1. Assists hospital staff, medical staff, public, and patients.2. Plans, organizes, prioritizes, and coordinates work to achieve functional area goals and maximum productivity and efficiency on a day to day basis.3. Participates in upgrades and testing of the coding/abstracting system and interfaces for same.4. Answers telephones consistent with Service Excellence standards, addresses and/or routes calls appropriately and in a timely manner.5. Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies

Knowledge, Skills and Abilities:

Knowledge1. Knowledge of Microsoft Office applications.2. Knowledge of department policies, practices and operations. Skills3. Perform data entry accurately with use of a keyboard and mouse. 4. Perform duties using computers and equipment required for scanning and indexing of documents5. Effective oral and written communication skills.6. Detail oriented and organized. Abilities7. Ability to recognize colors associated with color-coded filing system.8. Ability to learn the advanced aspects of the various indexes, storage, tracking, and retrieval systems.9. Ability to retrieve, reproduce, deliver, track, and file records using various equipment and systems in the facility and offsite.10. Ability to review records and verify patient information.

AVMC Values:

All AVMC employees will effectively demonstrate these values:

• Patients Come First
• We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership
• We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork
• We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty
• We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence
• We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation
• Our can-do attitudes, creativity, and resourcefulness empower usto improve the patient's experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion
• We have genuine empathy, show kindness, and encourage and advocate for each other.

Education and Experience:

Education

• RN or MBBSExperience Minimum of 3+ years CDI or inpatient coding experience in an acute care setting required

ICD-10-CM/PCS

proficiency required Required Licensure and/or

Certifications:

Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS).

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Attendance and Punctuality Policy
• Ability to adhere with AVMC Leaves of Absence Policy
• Ability to adhere with AVMC Paid Time Off (PTO) Policy
• Ability to adhere to the department dress code
• Ability to organize work and establish priorities
• Ability to expand on own initiative in performance of duties
• Skill and ability to follow the telephone etiquette/standards
• Ability to function effectively under pressure and meet time parameters
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC
• Ability to maintain the confidentiality of patient, hospital and department information
• Ability to adhere to safety rules and regulations
• Safely and effectively uses all equipment necessary to carry out duties
• Ability to interpret and function under hospital and department policies and procedures
• Conforms with required and appropriate accreditation and regulatory requirements
• Conforms with and supports hospital quality assurance and improvement guidelines
• Ability to participate effectively in department and hospital staff education
• Display a willingness to work as a team player
• Ability to give and support the highest level of patient/customer satisfaction at all times
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the

Code of Conduct Physical Requirements and Working Conditions:

Work is usually performed in a normal office environment and may require long periods in sedentary position performing one function.

• Trips within the facility and to onsite storage areas will be required to retrieve or deliverrecords.

Frequent use of scanner, keyboard and video display terminal.