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Clinical Documentation Spe II

Job ID: 958659
Facility: Vidant Health
Location: Greenville, NC
FT/PT: Full-Time
Reg/Temp: Regular
Date Posted: Aug 4, 2022

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Job Description

Vidant Health

About Vidant Health

Vidant Health is a regional health system serving 29 counties in eastern North Carolina. We are working every day to improve the health of the 1.4 million people we serve. Vidant Health is made up of 8 hospitals, physician practices, home health, hospice, wellness centers and other health care services. Vidant Medical Center is affiliated with the Brody School of Medicine at East Carolina University. As a major resource for health services and education, Vidant Health strives to support local medical communities and to work with providers throughout the region to deliver quality care. Our goal is to enhance services that are available locally and to eliminate barriers involving time, distance and lack of awareness that sometimes prevent patients from receiving the care they need.

Responsibilities

Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.

Analyzes data and reports quality issues to Supervisor and/or Manager.

Records appropriate admission status, working DRG & LOS info in CDI Tracking tool.

Comprehensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and accurately identifies physician query opportunities. Creates appropriate and compliant queries.

Reviews medical record every 24-48 hours as appropriate for changes in clinical condition or to ensure issues discussed and clarified with the physician have been documented in patient's chart.

Updates CDI Tracking tool to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate for intradepartmental communication.

Collaborates with coding staff, as needed, to determine appropriate DRG and required documentation.

Utilizes clinical skills to identify documentation opportunities that reflect PDx, comorbid conditions, complications, procedures, severity of illness, Risk of mortality, PSIs, acuity and resource consumption.

Performs concurrent education of physician and staff regarding best practice.

Stays current with and conducts on-going clinical documentation management program education.

Attends and participates in educational conferences

Participates on departmental and house wide committees as appropriate.

Provides overview of Clinical documentation Improvement to new staff, including physicians and other members of the interdisciplinary team.

Effectively communicates with physicians and other members of the interdisciplinary team to clarify potential documentation opportunities.

Provides clinical expertise and references to the coding staff.

Communicates with physician to ensure that request for documentation has been noted.

Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.

Follows established guidelines for reconciling final coded DRG assigned at the time of discharge.

Facilitates concurrent performance improvement activities.

Demonstrates acceptable level of Value Based behaviors.

Follows Patient Safety guidelines, organizational policies and procedures, professional standards of care, best practices, and regulatory requirements related to patient care quality.

Consistently uses good judgment and thinks critically in order to make correct decisions.

Collaborates effectively with departmental/program staff to achieve goals and objectives.

Delegates appropriately to maximize skill set, productivity and effectiveness.

Educates the interdisciplinary team regarding coding, documentation and quality.
Participates in special projects, and/or hospital committees pertaining to CDI initiatives.

Identifies strategies to evaluate and modify the clinical documentation program.

Maintains productivity and optimum client caseload for position.

Analyzes data and reports quality issues to Supervisor and/or Manager and submits all departmental reports in a timely manner.

Attends department/program meetings regularly.

Minimum Requirements

ADN, BSN, MD or equivalent is required

3 years recent CDI experience is required

Certification (CCDS or CDIP required)

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