Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Outpatient Clinical Documentation Specialist I RN facilitates modifications to clinical documentation through extensive concurrent interactions with physicians and other clinicians to provide an accurate picture of true acuity and clinical condition of the patient, highest level of specificity, medical necessity and the documentation support the services provided to the patient in the outpatient setting. The specialist shall review and evaluate selected patient 's medical records for overall quality and completeness. The specialist will educate physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues, and relevant quality and performance improvement opportunities. The specialist will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels. This individual uses clinical expertise and leverages past work clinical experience in addition to familiarity with coding guidelines, DGs, reimbursement methodology, compliant coding and billing practices, payer policies, coverage determinations, denial data to identify opportunities that are compliant and appropriate to achieve maximum results. This individual also supports other team members, shares knowledge and role models the professional standards of behavior.
EEO/AA/Disability/Veteran

• 1. Performs focused clinical medical record reviews and of discharged outpatient patients to identify the most appropriate diagnosis and the medical record documentation supports services rendered. Performs initial reviews, post discharge case reviews, retrospective review and analysis. Performs and supports other types of clinical documentation record reviews to ensure documentation sufficiently supports services rendered.
• 1.1. Completes the initial review within 24-48 hours of discharge
• 1.2. Completes clinical record reviews to ensure coding is supported and documentation elements are met and documentation by the providers to the greatest specificity.
• 1.3. Collaborates with coding staff and other departments throughout the health system to ensure the chart has all of the necessary documentation to support the most accurate coding.
• 2. Educates internal staff on clinical documentation documentation and coding guidelines. Develops and conducts ongoing training, education to ensure charts have all the necessary documentation to support the most accurate coding for services rendered. This includes training, education, and documentation improvement opportunities and trending for new and existing staff including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals.
• 3. Develops and supports strong professional relationships with team members, coding staff, clinical and operational department leadership, and medical providers across the system and others necessary to advance the department goals and initiatives.
• 4. Utilizes a compliant query process per guidelines and policy when conducting all queries. Follows each query through to closure including complete documentation on ongoing follow up activities, communication, and outcomes.
• 5. Works collaboratively with physician and nursing leadership to ensure positive program outcomes
• 6. Provides in person CDI training to providers one on one, during staff meetings or department meetings. Creates custom dashboards, score cards, and messages department performance metrics and CDI opportunities on a regular basis to work collaboratively with departments to improve quality of clinical documentation.
• 7. Assists in other monitoring activities, special department projects or other needs as determined by the department manager.
• 8. Provides ongoing CDI team learning opportunities through sharing of professional knowledge.
• 9. Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
• 10. Supports and implements quality measures as identified by department manager.
• 11. Identities opportunities of performance improvement and leads initiatives from initial assessment through post implementation monitoring.
• 12. Performs other duties as needed to support program and its initiatives.

EDUCATION

Registered Nurse with active license, BSN strongly preferred. Coding credential through AAPC or AHIMA preferred.

EXPERIENCE

At least three (3) years of recent acute care nursing experience required. Clinical expertise required.

LICENSURE

RN license required. Must obtain a CCS or COC coding credential within 12 months of hire. Must obtain and hold CCDS-O (Certified Clinical Documentation Specialist-Outpatient through acdis upon reaching eligibility after two years in the position.

SPECIAL SKILLS

Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in the use of medical record to extract data . Working knowledge outpatient and professional payment methodology or willingness to upskill in coding and necessary revenue cycle elements needed to be effective in role. Computer PC literacy required, including the ability to take data and translate into dashboards and executive summaries to share with leadership and department heads. Must be able to work collaboratively and independently. Must be able to train, educate, present knowledge and information to a wide range of audiences, including tailoring messaging and materials. Must be flexible with responsibilities in order to meet departmental needs. Must have keen eye to detail.

PHYSICAL DEMAND

Ability to communicate clearly and confidently to providers the program goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication. Must be able to travel for face to face meetings and training, as needed to support the work and program goals.

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