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Heywood Hospital Clinical Doc Improvement Specialist, Medical Records in Gardner, Massachusetts

Job Requirements Minimum Work Experience * Minimum of two years in nursing or other clinical setting, coding, process improvement or case management/ utilization review in an acute care setting Minimum Licenses and Certifications * The CDI specialist should ideally possess one or more of the following credentials: RN, BSN, CCS, RHIT, CCDS, CDIP Required Skills * Demonstrates strong organizational and leadership skills and able to work with little or minimal direct supervision * Strong communication (verbal/written) skills adaptable to a wide variety of interpersonal encounters within the healthcare system along with the ability to present ideas and concepts effectively to physicians, management, and other clinical staff * Demonstrates the ability to develop and maintain supportive collaborative relationships with physicians, coders and other healthcare providers * Demonstrates highly developed critical thinking, problem solving skills, self-directed, and motivated with strong computer skills Organizational Expectations Demonstrates mature professional behaviors, (i.e. tact, empathy and diplomacy). Promotes a positive working environment. Funct*ional Demands* Physical Requirements Exerts 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), and handles (seizing, holding, grasping, turning, or working with hands). Occasional stooping (bending the body downward and forward by bending the spine at the waist), crouching (bending the body downward and forward by bending legs and spine). Essential Functions * Facilitates and obtains appropriate provider documentation within the EHR for clinical conditions and treatment required for the accurate representation of severity of illness, risk of mortality, and complexity of care of the patient * Demonstrates coding skills with working knowledge of ICD-10 Coding, MS-DRG’s, APC-DRG’s, CC’s, and MCC’s. Strong knowledge of disease process, pathophysiology, anatomy and new/emerging technologies. Able to utilize and interpret AHA Coding Clinic and Coding guidelines * Keeps current on federal and state legislation as it relates to impacts on coding/reimbursement compliance. Has familiarity with IPPS including the comprehensive error rate Testing (CERT) program and familiarity with the short term hospital PEPPER report * Reviews inpatient medical records while patients are still in house (concurrent review) for appropriate clinical documentation. Review includes new admissions and re reviews every 2-3 days until patient is discharged * Communicate with clinicians and physicians to ensure timely and accurate clinical documentation and provides training and education as needed * Performs focus reviews at the discretion of the HIM Director and CFO. Able to recognize and disseminate to providers the synergies of accurate clinical documentation for the both the physician and the hospital * Educates the medical staff and other clinicians using a variety of teaching methods including “just in time” training to establish optimal provider documentation at admission and through the patients stay * Assures timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcome data through ongoing performance monitoring and queries * Calculates and monitors CMI and other CDI KPI metrics to track areas for performance improvement to appropriately reflect the impacts of the CDI program * Collaborates with the HIM coding staff and serves as subject matter expert in clinical best practices, Medical diagnoses/procedures and provider clinical documentation * Improves coding specificity by educating physicians and other clinicians involved in the care of the patient about the necessity of providing complete and clear documentation of the care provided during the patients stay via queries, face to face communication and/or other educational tools * Demonstrates knowledge of what constitutes complete and accurate medical record (i.e., complete and thorough clinical documentation beginning with the clinical presentation, reason for admission and medical necessity, along with response to treatments, interventions and outcomes thru discharge of the patient from the facility) * Sends queries to providers to ensure accuracy of the clinical documentation specificity and that it is reflective of the actual acuity of the patient * Participates in educational programs and in services in order to maintain and exceed excellence in clinical and coding skills * Ability to obtain documentation relevant to denials related to clinical validation, medical necessity, Coding and DRG changes * Able to identify areas of need and focus thru report analysis. Shares data findings with HIM Director, CMO and Administrative staff as required * Acts as facilitator or conduit between providers and other staff to support CDI, Utilization review and coding * Follows the Association of Clinical Documentation Integrity Specialists (ACDIS) Code of Ethics. * Maintains confidentiality of patient information, in addition to hospital system proprietary information and individual physician practice pattern data * Updates and maintains the CDI database system denoting all key information utilized in the tracking process for CDI functions Facility: Heywood Hospital Department: HH. MEDICAL REC.-,6240 Regular or Temporary Position: Regular Position Control #: 2000.66580.8077 Position Hours: 40 Shift: Day Job Title: Clinical Doc Improvement Specialist, Medical Records Location: Gardner, Massachusetts Posted Date: 01/30/2021

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