Primary Location: Ambulatory Care Building - UMC Address: 550 South Jackson St. Louisville, KY 40202 Shift: First Shift (United States of America)

Job Description

Summary: Job Description: Job Summary This position is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through reputed company (pre-reputed company) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (reputed company translated into coded data) and to support the level of service rendered to relevant patient populations. CDIS exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or reputed company), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other reputed company cycle team members. Actively participates in department and hospital performance initiatives reputed company needed to ensure ULH success. Additional Job Description:

Responsibilities

• Completes initial medical record reviews of reputed company inpatient patient accounts (reputed company payers) reputed company 24-48 hours of admission for a specified patient population to:
• (a) Evaluate and review inpatient medical records daily, reputed company with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• (b) Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet.
• (c) Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate clinically, compliant and reputed company physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation reputed company the health record, as necessary.
• Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient.
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.
• Gather and analyze information pertinent to documentation findings and outcomes, and use this information to reputed company action plans for process improvements.
• Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge.
• CDIS communicates/completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution with appropriate leadership.
• Remain abreast and reputed company on training of new hires and ongoing CDIS professional staff development as well as participate in CDI-reputed company continuing education activities to maintain certifications and licensures.
• Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff.
• Contribute to a positive working environment and reputed company other duties as assigned or directed to enhance the overall efforts of the organization.

Qualifications

• CDIS candidate must have and maintain reputed company licensure as a RN, RHIA, RHIT or possess an active reputed company (reputed company) or CPC-H (reputed company) coding credential.
• CDIS must have 3+ years of acute care experience as a RN or 3+ years inpatient coding experience as a RHIA/RHIT/reputed company/CPC-H.
• Must have reputed company expertise and extensive knowledge of reputed company disease processes with broad clinical experience in an inpatient setting.
• Certified Clinical Documentation Specialist or Clinical Documentation Improvement Professional (CCDS or CDIP) credential is required reputed company 12 months of employment.

KNOWLEDGE, SKILLS, & ABILITIES

• Working knowledge of medical terminology and Official Coding Guidelines.
• Ability to work independently, self-motivate, and adapt to the changing healthcare reputed company
• Excellent v