• Job Description

  Req#: 23-76089
  
  
  Job Description
  
  Job Tittle: Clinical Documentation Specialist
  Location: Remote
  
  Job Description:
  • Responsible for improving the overall quality and completeness of clinical documentation.
  • Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Other payers).
  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.
  • Other duties as assigned.
  • Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Other payors as specified).
  • Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using Compliant Documentation Program Management® (CDMP®) guidelines.
  • Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patients chart.
  • Facilitates concurrent documentation from all disciplines (physicians, case managers, discharge planners, nurses, etc.) to capture best practice Quality Indicators for specific diagnoses (currently including Heart Failure, Acute Myocardial Infarction, Pneumonia, and Surgical Infection Prevention) to support the CMS/JCAHO Hospital Quality Alliance and CMS/Premier Demonstration Project Requirements.
  • Reviews clinical issues bi monthly with coding staff to assign a working DRG.
  • Demonstrates knowledge of DRG payor issues, documentation opportunities, clinical documentation requirements and referral policies and procedures.
  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
  • Process discharges by updating the DRG Worksheet and Quality Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnoses and documentation of quality measures.
  • Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
  • Assists with management of CDMPTrak. Serves as a member of the CDMP Task Force.
  • Monitors and addresses timeliness in documentation.
  • Performs other duties as assigned to meet the needs of the department.
  
  Skills:
  • 5+ years acute care nursing or Clinical Documentation Specialist experience required.
  • Critical care and/or ICU experience preferred.
  • Requires excellent observation and verbal/written communication skills, analytical thinking, and problem solving.
  • Requires strong interpersonal skills including ability to communicate well with others.
  
  Education:
  • Associate degree in nursing.
  • Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact).

• About the company

  Established in 2000, LanceSoft is a Certified MBE and Woman-Owned organization, and a pioneer in providing premium end-to-end Global Workforce Solutions and IT Services to diverse clients across various domains.

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