Billings Clinic Clinical Documentation Specialist IP in Billings, Montana
Clinical Documentation Specialist IP
Full-Time (.75 or greater)
1.00 = 80 hours
The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical documentation in the inpatient medical record with the goal to obtain the most accurate and complete physician documentation that appropriately supports the severity of a patient’s illness, mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via written and/or verbal communications for clarification of clinical documentation. He/she works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. Provides ongoing education related to documentation requirements and opportunities to all providers.ESSENTIAL JOB FUNCTIONS
• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Performs admission reviews within 24 to 48 hours for specific patient populations to facilitate appropriate clinical documentation and to ensure that the patient’s acuity level and severity of illness score are accurately reflected in the medical record.
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results, diagnostic information, and treatment plans, and utilizes his/her clinical skills and knowledge of coding guidelines to identify documentation opportunities to impact and reflect severity of illness throughout a patient’s stay.
• Queries physicians and non-physician providers verbally and in writing on a daily basis according to compliant query guidelines in order to obtain appropriate clarity and specificity of documented diagnoses and medical conditions in the medical record.
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis, secondary diagnoses, procedures, and assigns a working DRG. Enters working DRG in Cerner.
• Provides education to physicians in a one to one setting regarding documentation specificity and the impact of specificity on acuity levels.
• Utilizes monitoring tools to audit and track the progress of the concurrent review program, interprets tracking information, and reports findings in concurrent review team meetings as well as to providers and other key stakeholders.
• Utilizes medical staff established criteria for complications to assist in appropriate documentation and complication coding.
• Responds to and reviews clinical coding questions from the coding staff and provides clinical direction. Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic medical record (problem list, diagnostic information, history, etc.) for existing chronic or pre-existing conditions that should be reflected in the current hospitalization.
• Regularly attends physician meetings and provides education to physicians and non-physician providers regarding clinical documentation and coding guidelines. Serves as a resource to all providers regarding documentation best practices.
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• May be required to cross-train to outpatient HCC and risk adjusted coding review as necessary.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.
Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
Performs all other duties as assigned or as needed to meet the needs of the department/organization.
Department or Level Specific Duties and Responsibilities
Billings Clinic is a community-owned, not-for-profit health care organization in Billings, Montana with approximately 4,000 employees, including over 400 physicians and advanced practitioners. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital. Learn more about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality.
Billings Clinic is committed to the principles of Equal Employment Opportunity. All policies and processes are designed toward achieving fair and equitable treatment of all employees and job applicants. Employees are encouraged to discuss any concerns they have in this regard with their immediate supervisor and/or the Vice President People Resources. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, creed, religion, national origin, gender, gender identity, sexual orientation, age, marital status, genetic information or disability.