Job Summary
Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment.
Essential Functions
All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference.
Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.).
Assigns a working DRG for health care team discharge planning and CDI use.
Performs other duties as assigned.
Supervisory/Management Responsibilities
This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
Education - Associate degree in Nursing, Health Information Management, or related field of study
Experience - Two (2) years - adult medical/surgical/critical care/ER/PACU nursing coding or related experience
In Lieu Of
In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP
Required Certifications, Registrations, Licenses
RN/RHIA/RHIT/CCS/CIC or Licensure in related field of study
Knowledge, Skills and Abilities
Strong computer skills
Strong communication skills with ability to interact with providers.
General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred
Work Shift
Day (United States of America)
Location
Corporate
Facility
7001 Corporate
Department
70017540 Clinical Documentation Integrity
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