HIM Clinical Documentation Specialist

Responsibilities:

•  Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines 
• Clinically interpret and validate diagnoses and treatment plans to ensure documentation reflects the patient’s true condition and severity of illness 
•  Provide clinical care teams with ongoing education and training on current trends in documentation and coding 
•  Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the Clinical Documentation department 
• Enter clinical review data and related anticipated follow-up in EPIC PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG 
• Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity 
• Negotiate documentations improvements through compliant, clinically supported decisions 
• Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system 
• Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes 
• Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation 
• Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation 
• Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed 
• Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation 
• Proficient in negotiating complex systems to effect positive change 
• Ability to interpret, adapt, and apply guidelines and procedures 
• Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems 
• Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding 
• Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary 
•  Serve as a resource on DRG issues 
• Serve as a clinical resource, applying medical expertise to guide documentation accuracy and integrity 
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures 
• Other duties as assigned to support the unit, department, entity, and health system organization

Credentials:

• RN, NP, or PA licensure is required.
• RHIA, RHIT, and CCS certifications are preferred. 
• CCDS or CDIP is preferred. 

Education or Equivalent Experience:

• Bachelor's degree in healthcare field is required.
• 3+ years of healthcare experience is required. 
• Master's degree is preferred.
• Clinical experience with knowledge of Medicare reimbursement system & coding structures is preferred.