Clinical Documentation Specialist, Clinical Documentation Improvement
Hennepin HealthcareAbout the role
Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.
Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.
SUMMARY
We are currently seeking a Clinical Documentation Specialist to join our Clinical Documentation Improvement team. This full-time role will primarily work remote (Day, M- F). Purpose of this position: Under the direction of Coding and Documentation leadership, provides active concurrent review, feedback, and education to physicians and healthcare providers to improve documentation of all conditions and treatments in the inpatient medical record, to ensure an accurate reflection of the patient condition in the associated MS-DRG assignments, case-mix index, severity of illness and risk of mortality profiling and reimbursement.Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin. RESPONSIBILITIES
- Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
- Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
- Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
- Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP’s) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
- Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
- Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge whenever possible
- Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notif
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