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Coder / Clinical Documentation Information Specialist

Coder / Clinical Documentation Information Specialist

Memorial Physician PracticesWinchester, KY, US
22 hours ago
Job type
  • Full-time
Job description

Clark Regional Medical Center

Overview

Who We Are : People are our passion and purpose. Clark Regional Medical Center is a 79 bed community hospital featuring updated technology including new and expanded services such as Diagnostic Services, larger capacity Emergency Services, home-like Labor and Delivery Suites, and a skilled nursing facility. The campus also includes a 45,000 square foot Medical Plaza housing the Clark Clinic, Diagnostic Center for Women, Center for Rehabilitation, Specialty Clinic and Anticoagulation Clinic.

Where We Are : Winchester offers a truly original experience to all with so much to do and see. Just a short drive from Lexington, the "Horse Capital of the World," and the Red River Gorge, you can experience all the beauty and excitement nature has to offer.

Benefits

  • Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
  • Competitive Paid Time Off
  • Employee Assistance Program - mental, physical, and financial wellness assistance
  • Tuition Reimbursement / Assistance for qualified applicants
  • Membership discounts with local gyms and community businesses
  • Free Parking
  • And much more

Qualifications

  • Preferred Certifications : CCDS or CDIP
  • Required Certifications : CCS or CIC for coders
  • RHIA or RHIT (Preferred)
  • Minimum 2 years In-Patient Acute Care Coding experience (Highly Preferred)
  • Other Qualifications

  • Licenses : Licensed Registered Nurse (RN)
  • Licensed Practical Nurse (LPN), or combination thereof
  • Summary

  • The Market Clinical Documentation Specialist's primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.
  • Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Integrity Specialist (CDIS) will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients.
  • Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.
  • Responsibilities

  • Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures, ensuring accuracy of medical record documentation to support maximum reimbursement.
  • Concurrently abstract information from the medical record in accordance with the conventions and rules associated with ICD-10.
  • Abstract information from the medical record in accordance with abstracting guidelines as defined by Meditech, the medical center, HCFA, state and federal databases.
  • Other duties as assigned by the Director.
  • Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
  • Must be able to work in a stressful environment and take appropriate action.
  • Hybrid work schedule will be considered.
  • Must maintain credentials through continuing education.
  • Essential Job Functions

  • Conduct daily reviews of inpatient medical records to identify missing, vague, or incomplete diagnoses and procedures, whether in the nursing unit or on the computer.
  • Conduct timely follow-up reviews of clinical documentation to ensure that queries left in the medical record have been answered by the provider.
  • Utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes.
  • Query physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines and LifePoint Hospitals policy.
  • Track and trend opportunities for improvement through the query process using approved metrics reporting.
  • Conduct educational sessions with physicians and other health care team members on documentation requirements.
  • Conduct CDI onboarding education for all new admitting physicians as part of the hospital's orientation program.
  • Review clinical issues and identified query response concerns with physician advisors.
  • Participate in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation.
  • Stay current with CMS IPPS, AHA Coding Clinic, and Official Guidelines for Coding and Reporting related to ICD-10.
  • Participate in department and facility Quality and Performance initiatives.
  • Work closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics.
  • Collaborate with the Director of Quality, Medical Staff Credentialing and medical staff leadership to ensure effective monitoring and successful completion of identified plans for improvement.
  • Prepare and present educational programs related to clinical documentation issues and coordinate with clinical staff, physicians, compliance and coding staff.
  • Provide regular progress reports toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
  • Establish cooperative working relationships with diverse groups and individuals, medical staff, and other health care disciplines at all levels of employees.
  • Develop and maintain professional working relationships with medical staff, clinical staff, medical records, and business office staff.
  • Maintain knowledge of disease characteristics that directly impact patient health.
  • Collaborates and consults with health care team members to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding.
  • Understand legal and ethical issues pertaining to confidentiality and liability in coding activities.
  • Attend meetings as required and participate on committees and teams as directed.
  • Functional Demands

    Functional Demands and Populations Served : Does not treat or care for patients. Type of Protected Information Accessed : Demographic, Clinical, Insurance, Financial; Complete Medical Record. Exposure to Bloodborne Pathogens : Yes. Physical Requirements : Dexterity and effort required at a moderate level; position may involve physical activity.

    EEOC Statement

    Clark Regional Medical Center is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

    Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.

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    Clinical Documentation Specialist • Winchester, KY, US

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