Clinical Documentation Spec Coding Documentation Program Job
Location: Lebanon NH - New Hampshire
Rate: N/A (Permanent) Equivalent to N/A
Day JOB SUMMARY: Under direction of the Coding Manager, facilitate improvement in the overall quality, completeness and accuracy of medical record documentation. Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Care Management and Coding staff to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate, and that reimbursement is received for the level of services rendered to patients with DRG-based payors. Educate all members of the patient care team on documentation guidelines on an ongoing basis. Collect and analyze data to provide reports and make recommendations. Work collaboratively with staff to provide staff support, including assistance with problem solving and recommendations for process improvements. Collaborate with other disciplines regarding proposed DRG changes and proposed quality concerns, and communicate with the attending physician or medical director regarding these issues to the appropriate performance improvement committee. MINIMUM EDUCATION & EXPERIENCE: Current New Hampshire Registered Nurse license with a minimum of 3 years of applicable experience required. Up-to-date clinical knowledge to be able to efficiently and concurrently review medical records, understand clinical picture of the patient condition and identify opportunities for improved documentation. Current knowledge of DRGs and payment regulations preferred. Must have the ability to create and maintain strong relationships with the Medical Staff and confidently discussing clinical diagnoses. Excellent verbal and written communication abilities required. Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up . Must have good organizational skill including project management, with attention to detail and accuracy . Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff . Must have the following computer competencies: data entry and analysis (Excel, Access or other database software), word processing (MS Word), and presentations (PowerPoint). Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred
