Job Description

Job Description

The Clinical Documentation Coordinator, under the guidance of the CDI Director and Managers, assists with all clinical documentation initiatives for the hospitals/HealthSystem, including processes and workflow design, implementation and continuous process improvement. Reviews medical records concurrently and/or retrospectively for clinical indicators and associated provider documentation for accuracy and specificity and supporting compliant CDI reviews and query processes that allow for optimal final coding accuracy. Serves as a CDI resource for Clinical Documentation Specialists, providers and CDI leadership in areas of clinical documentation improvement initiatives.

Responsibilities

1. Documentation Review
   1. Performs concurrent and/or retrospective review of acute inpatient medical records for clarity and specificity of physician
   2. Places queries for physicians in the medical record, requesting clarification of the principle diagnosis or secondary conditions of the patient.
   3. Provides continuous education to physicians and case managers regarding important documentation issues.
   4. Performs random retrospective audits to identify trends or problem areas for documentation and coding. Analyzes DRG data and length of stay/resource utilization patterns for process improvement initiatives
2. Quality
   1. Operates within the compliance guidelines of Medicare and Medicaid Services.
   2. Always considers compliance and displays ethical decision-making skills.
   3. Knows, understands, and complies with applicable Federal and State Laws, and the Lake Code of Conduct, Corporate Compliance Policies and Procedures, reporting requirements, appropriate lines of authority, Ethical and Religious directions for Catholic Health Care Services, and all other regulatory agencies and accrediting bodies' requirements.
3. Collaboration and Partnership
   1. Works collaboratively with the coding and medical management departments in order to integrate and foster the relationship between Health Information Management and Case Management.
   2. Works harmoniously with other departments to ensure proper reimbursement for services rendered.
   3. Functions as a resource to the case management team regarding patient status, medical necessity and discharge planning. Assists with problem solving initiatives within the case management realm, process improvements and the implementation of new processes.
   4. Has a good working relationship with Managers and Administrators throughout the facility.
4. Research/Education
   1. Designs and develops forms such as queries, clinical information forms, etc., to assist with greater specificity in documentation by physicians.
   2. Measures the progress and quality of documentation improvement using reports from CDI database for DRG rates, CC/MCC rates, physician response, etc.
   3. Develops profiling reports by service, physician, diagnosis and DRG to use as educational tool for physicians, and reporting effectiveness of CDI program by physician to management.
   4. Performs random retrospective audits to identify trends or problem areas for documentation, using this information as educational opportunity for CDI specialists and coders.
5. Other Duties as Assigned
   1. Performs other duties as assigned or requested.

Qualifications

• Must possess one of the following experience requirements: 1. RN with 3 years clinical nursing experience in an acute care facility or 2. RHIA or RHIT with 5 years acute care coding experience with CCS certification.
• Associate's or Bachelor's degree in Nursing or HIM field
• Knowledge of ICD-10 Codes Prefer experience in Documentation Improvement.
• Louisiana licensed RN or RHIA with CCS or RHIT with CCS

Franciscan Missionaries of Our Lady Health System

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