About the role
The Clinical Documentation and Performance Improvement Specialist is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (later translated into coded data) and to support the level of service rendered to relevant patient populations.
This position exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other revenue cycle team members. The Clinical Documentation and Performance Improvement Specialist is also responsible for managing the department's databases and data extract programs.
Provides reports, promotes the use of comparative information and analyzes and recommends areas of opportunity for improved efficiency for administration, medical staff quality improvement and strategic planning purposes.
Participating at the organizational level in clinical documentation improvement initiatives. Completes initial medical record reviews of selected inpatient patient accounts upon admission. Evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, and initiate a review worksheet. Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary. Formulate clinically, compliant and credible physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient. Collaborate with staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge. Identify patterns, trends, variances, and opportunities to improve documentation review processes.
Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff. Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization. Educate providers about identification of disease processes that reflect SOI, complexity, and acuity.
Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team Collects accurate and concise data from charts and other documents to monitor indicators or perform focused studies to assess compliance with accreditation, licensure or hospital policies and procedures.
Identifies deviations from normal course of events. Analyzes data and utilizes performance improvement tools and techniques, such as graphs, run charts, control charts in performance improvement reports to the appropriate Medical Staff Departments and/or committees. Shares and displays data in formats for ease in analysis for ongoing performance improvement.
Coordinates the review of medical records as needed for submission to TJC, CMS, and QIO validation and reliability. Communicates documentation needs to appropriate staff for ease in abstraction of data. Ensures data entry is completed timely, exports data to Qnet exchange, prints edit reports, researches edits and re-exports data.
Works with various departments, physicians, teams and committees to coordinate the performance improvement process. Submits data to national registries. Supports ongoing improvements in data collection methods.
Develops and maintains familiarity with hardware, software and reporting tools. Including but not limited to Meditech, Microsoft Office Word, and Microsoft Office Excel. Assures that all information generated and circulated is treated with strictest of confidentiality.
Qualifications Education Requirements and Other
Education Level: Associate Degree or Higher. Certification/Licensure: RN or RHIT, RHIA, CCDS. Experience
Three or more years previous clinical acute care medical/surgical nursing experience preferred. One to three years’ experience with chart review, PI process, and/or CDI work experience highly preferred. Computer skills required.
Works well under stress or tight deadlines and remains flexible to changing systems and processes.
Days