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Clinical Documentation Specialist

Job Description

Additional Job Information

  • 40 Hours per Week -
  • Monday - Friday -
  • Days -
  • Remote (Work from Home) -

  • Job ID: 1205924
    Employment Status: Full-Time
    More Information:

    Boone Hospital Center is a 394-bed full service hospital located in Columbia, MO. It is a regional referral center located in the center of the state. The hospital provides progressive healthcare programs, services, and technology to people in 26 mid-Missouri counties. Although the hospital is full service, areas in which Boone Hospital Center excels are cardiology, neurology, oncology, surgical, obstetrical services, and numerous other specialties. The hospital maintains a 24-hour emergency center with hospital-based ambulance service and a helipad for incoming emergency air transportation.  Recognizing its excellence in nursing care, Boone Hospital Center has been certified as a "Magnet Hospital" by the American Nurses Credentialing Center.
     

    The CDMP department provides a concurrent review of the patient¿s medical record to ensure accuracy of documentation. Registered nurses work closely with medical coders, physicians and other healthcare professionals to evaluate the patient¿s condition and the associated documentation.


    Overview


    Role Purpose

    Uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.


    Responsibilities

  • Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.
  • Utilizes hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
  • Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
  • Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.
  • Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation improvement efforts, with all providers

  • Minimum Requirements

     

    Degree

  • Associate's Degree
  • - Nursing/Healthcare related

     

    Experience

  • 2-5 years

  •  

    Preferred Requirements and Additional Job Information

     

    Degree

  • Bachelor's Degree
  • - Nursing/Healthcare related

     

    Supervisor Experience

  • No Experience
  •  

    Licenses & Certifications

  • RN
  •  

    Clinical - Direct Skills

  • Intensive Care Unit (ICU) -
  • Case Management -
  • Medical/Surgical -
  •  

    Clinical - Non Direct Skills

  • Clinical Documentation Specialist -
  •  


    Benefits Statement

    Note: not all benefits apply to all openings

    -  Comprehensive medical, dental, life insurance, and disability plan options
    -  Pension Plan*/403(b) Plan
    -  401(k) plan
    -  Tuition Assistance
    -  Health Care and Dependent Care Reimbursement Accounts
    -  On-Site Fitness Center (depending on location)
    -  Paid Time Off Program for vacation, holiday and sick time

    *Pension does not apply to Memorial Hospital, Memorial Hospital East, Memorial Medical Group, Alton Memorial or Parkland Health Center


    Legal Statement

    The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.

     

    Equal Opportunity Employer