Job Description
JOB DESCRIPTION
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Contractors must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient's rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings. Contractors must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions.
* The functions performed by employees in this job family will vary by level or the area(s) to which assigned, but may include (and not be limited to) the following:
* Documentation and Coding Analysis: 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.
* Initiates medical record review within 24 to 48 hours of admission. Monitors, systematically, the targeted medical records within at least 48 hours unless otherwise indicated) to determine compliance to established documentation standards. Conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.
* 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.
* Partners with the Inpatient coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes.
* Advises and counsels clinical providers in assigned areas in clinical documentation and coding concepts, query procedures and processes.
* Responsible for units and/or service lines assigned by manager.
* Maintains liaison with department or service line clinical providers in documentation Integrity
* Suggests improvements to enhance documentation Integrity or clinical provider documentation process.
* Documentation Integrity Strategies and Provider Partnership: Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation Integrity efforts, with all providers.
* Addresses abnormal ancillary test findings when they occur and query physicians on a current basis to include face-to-face interactions regarding the impact on patient care and DRG assignment.
* Initiates physician interaction when 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.
* Assists CDI service line teams and leadership in the ongoing evaluation of clinical documentation and potential improvement initiatives.
* Documentation Performance, Reporting and Enhancements: Performs ongoing documentation analysis for assigned units and/or service lines and submits documentation clarifications or queries to mitigate gaps or inconsistency in documentation, thus ensuring the accuracy of code capture and resulting outcomes.
* Assists other peers and leadership understanding variance and other documentation and CDI related barriers.
* Develops or recommends improvements/enhancements to documentation tools, provider engagement and/or processes related to documentation and related outcomes, as needed.
* Assists in reconciling query and non-query impact within the CDI data entry systems. Project management regarding clinical documentation initiatives and analysis of potential scope expansion or opportunity identification and resolution
* Performs other related and incidental duties as needed or required.
* Job Scope: Entry-level professional with limited or no prior experience; learns to use professional concepts to resolve problems of limited scope and complexity; works on developmental assignments that are initially routine in nature, requiring limited judgment and decision making.
* Performs the more routine CDI work and in a learning capacity, assists in the technical review of various types of medical records within expanding scope of clinical specialty and some exposure to additional complexity, as well as exposure to other projects.
* Knowledge: Requires basic clinical, coding and/or CDI knowledge and understanding of the theories, concepts, principles and practices of medical record documentation and/or data analysis.
* Learns to apply professional principles, theories, and concepts through work assignments.
* Job Complexity: Works on problems of limited scope; routine in nature. Follows standard practices and procedures in analyzing situations or data from which answers can be readily obtained.
* Close monitoring and partnership with preceptors/more experienced Clinical Documentation Integrity Specialists.
* Level of Supervision:
* Works under close supervision. Assignments are designed to provide training and practical experience that develops the incumbent's ability to apply CDI and coding principles, methodologies, and procedures.
* Decisions are limited to specific, task-related activities. Requires the manager's, Lead's or preceptor's review of the work performed, while in progress and at its completion, for accuracy, completeness, and conformance with detailed instructions.
* Work is primarily with existing, stable processes and procedures
* As the employee's skill level progresses, close supervision is relaxed.
* Customer Support & Interaction:
* Supervised and limited client interaction.
* As the employee's skill level progresses, supervision of limited interaction is relaxed.
Required Skills & Experience
MINMUM QUALIFICATIONS
Education Qualifications
* Bachelor's degree in Nursing, Medicine, Health Information Management or similarly related field of study
Licenses and Certifications
* RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred
* BLS - Basic Life Support
Experience
* Five (5) years of progressively responsible and directly related inpatient clinical experience.
* ICU/ED and Academic Medical Center experience preferred. Case management, utilization review and/or direct provider interaction experience, preferred.
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.