Description

Collaborates extensively with physicians, nursing staff, other patient caregivers, and coders to improve quality and completeness of documentation of care provided and coded. Facilitates concurrent modifications to clinical documentation to ensure clinical severity and reimbursement for services rendered. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Understands Case Mix Index, Severity of Illness and Risk of Mortality in relation to ICD-10 code set. Educates all members of the patient care team on an ongoing basis. Analysis of provider query responses and opportunities for documentation improvement in the Inpatient and Outpatient setting. This position works closely with Quality Management, Revenue Cycle departments, RAC, and Corporate Compliance to achieve system targets, initiatives, and ensure integrity. Performs other duties as assigned. Serves as an educational resource for all internal and external customers related to compliant documentation for DRG revenue assurance, compliance, quality outcomes and ICD-10.

Requirements

Minimum 3 years acute-care hospital experience as Documentation Specialist or Inpatient Coder.  AHIMA credential of RHIT or RHIA or CCS or CDIP or ACDIS CCDS required within 24 months of hire; Licensed RN preferred but must have coding experience.