JOB DETAILS

Department: Clinical Documentation Improvement
FTE: 1.00 (80 hours per pay period)
Workdays: Monday - Friday
Shift(s): Days
Shift Length: 8 hours
Location: Remote*
*Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.

Purpose of this position: Chiefly responsible for the reviewing of PSI/HAC accounts, involving reviewing encounters, noting documentation issues/concerns, reporting PSI/HAC at meetings, following up and reporting outcomes. Assists in the daily workload for clinical documentation specialists. Assists in the continuing education of CDI staff and providers (attending providers, PAs and APPs) around documentation. Communicating with Physician Liaisons, Quality, and other departments as necessary. Position will require considerable knowledge, experience, judgment, and ability to problem solve and have working knowledge of ICD10 CM and PCS documentation requirements and overall documentation requirements within Hennepin Healthcare. 

RESPONSIBILITIES

• Conduct coding consults and PSI/HAC reviews on daily basis

• Validate reported PSI codes against AHRQ technical specification and CMS reported HAC’s with assistance of the Medical Director of Clinical Documentation Improvement and Physician Liaisons

• Maintain a copy of updated AHRQ PSI technical specifications from AHRQ website. And updates reportable HAC’s from CMS

• Review and compare quarterly or monthly reported PSI/HAC cases from Quality Department and SAS reports for accuracy

• Input data for each PSI/HAC Excel spreadsheets and Epic as directed. Enter events into MCCM and event system as needed for reporting purposes

• Report monthly PSI/HAC data to CDI and Inpatient Coding Manager, CDI Supervisor, Medical Director of Clinical Documentation Improvement and other departments and leadership as needed

• Participate and represent Clinical Documentation in meetings

• Identify documentation trends around PSI/HACs and assist in creating education for coding and clinical documentation staff

• Assist the Physician Liaisons with education for providers (Attending Physician’s, PAs and APPs)

• Participate in the final decision and recommendation regarding issues regarding PSI and HAC with Medical Director of Clinical Documentation Improvement, CDI and Inpatient coding Supervisors

• Run reports as requested after appropriate training

• Assist the CDI Supervisor with daily communication and workload for clinical documentation specialists

• Assist Clinical Documentation specialists with follow- up on query responses

• Assist in training and education of new clinical documentation specialists

• Be a resource for clinical documentation specialist regarding documentation and coding issues

• Conduct initial and continued stay reviews as directed by the supervisor and/or manager of the department

• Collaborate with HB Outpatient and Inpatient Educator on education materials for monthly roundtable meetings

• Assist the physician liaisons as necessary with questions around documentation and coding requirements

• Additional duties as assigned

QUALIFICATIONS

Minimum Qualifications:

• Associate degree in Nursing, Health Information Management or other healthcare related field

• Three to five years of experience working in CDI and/or Inpatient coding

• Certified Clinical Documentation Specialist (CCDS)

-AND-

•  Registered Nurse, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P)

Preferred Qualifications:

• Bachelor’s Degree in Nursing, Health Information Management or other healthcare field

Knowledge/ Skills/ Abilities:

• Proficiency with computer hardware (PC, laptop, etc.) and software (Microsoft Office, Epic Electronic Medical Record, 3M Encoder and other Coding, EMR and CDI systems, etc.), as well as the ability to learn/utilize programs on an ongoing basis

• Self-directed and self-motivated to work both independently and in a team atmosphere

• Contributes to process improvement activities and is adaptive to changing and adjusting workflow to meet the needs of the customer and the program

• Demonstrated proficiency in the ability and desire to develop positive working relationships with physicians and other professional health care staff

• Excellent collaboration skills (i.e. strong interpersonal and negotiation skills, ability to develop strong, trusting working relationships, in order to gain support and achieve desired results)

• Demonstrated ability to offer innovative and thoughtful ideas for process improvement

• Knowledge of care delivery documentation system and related medical record documentation

• Knowledge of age-specific needs and elements of disease process and related procedures

• Strong broad-based clinical knowledge and understanding of anatomy and pathophysiology

• Excellent written and verbal communication skills and critical thinking skills

• Working knowledge of inpatient admission criteria

• Working knowledge of overall inpatient documentation requirements

• Working knowledge of Medicare reimbursement system and coding structures