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Clinical Documentation Specialist-HIM

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Healthcare/Business Support
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140994 Requisition #
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HIM focuses on securing and maintaining health information and the management of health care information resources. Accurate, complete, secure patient information is essential to the delivery of safe, effective and reimbursable health care. We ensure that patient information meets regulatory compliance and accreditation standards. While this is not new, the means by which HIM is accomplishing these objectives is changing drastically and transforming the profession. 

Ideal candidate will have previous experience with clinical coding and documentation, analyzing and interpreting data and being able to communicate with the interdisciplinary team.

HIM services include document bar coding and imaging, chart corrections, medical record auditing, release of information, forms management, clinical documentation improvement and customer service. 

The primary purpose of the Clinical Documentation Specialist position is to coordinate accurate and complete clinical documentation through collaboration with MD Anderson staff and patient care team, reviewing the patient record throughout hospitalization and discharge, recording working DRG including coding, detailing review notes, and preparing the record for proper coding.

JOB SPECIFIC COMPETENCIES

Interaction and Education  Interacts with MD Anderson staff on topics of documentation improvement, coding, case mix, mortality index and expected mortality, length of stay index and expected length of stay, risk adjustment methodologies and models, and other documentation improvement topics.  Clearly articulates documentation topics and communicates effectively.  Takes initiative.  Answers the CDI phone line(s) and emails, presents at meetings, and communicates in groups and one to one.  Prepares guides and resources.  Educates members of the patient care team.  Communicates with physicians, APPs, case managers, coders and others to facilitate comprehensive medical record documentation.  Is an effective change agent, resource, educator, and communicator.   

Reviews and Queries  Validates documentation reflects the medical complexity and facilitates proper coding which provides an accurate accounting and reporting of the clinical severity and complexity of care including the principle diagnosis, present on admission comorbidities, present on admission (POA), CCs and MCCs, DRG and DRG weight, severity of illness, risk of mortality, expected mortality, expected length of stay, risk adjustment, and other factors and metrics derived from documentation and coding.  Advanced use of algorithms and models (i.e. mortality index, length of stay index, etc).  With each review, identifies and records the most appropriate working principal diagnosis and CC’s in compliance with coding guidelines and regulatory compliance.  Identifies opportunities in concurrent and retrospective documentation and address documentation opportunities. Self-motivated and able to prioritize work.  Conducts timely initial and follow-up reviews, documents review details, sends queries, and proactively and routinely takes action through conclusion to ensure documentation clarified with the treating provider(s) have been recorded in the medical record. Updates work-sheets at least every 48 hours or current expectation.  Outcomes focused.  Meets or exceeds productivity, quality, timeliness, and outcomes standards.

Change Readiness and Advance Professional Competence   Exemplify CDI expertise and innovation.  Demonstrate, and ongoing investment in and growth of, CDI knowledge, industry changes, innovations, and opportunities.  Keeps pace with changes, dynamic factors, and advances.  Adapts, applies expertise and innovation to support the institution’s goals and interests.  Continuous improvement, demonstrates change readiness, change acceptance, change management, and PI/QI methods and behaviors. Adapts and maximizes CDI practices, metrics, and outcomes.  Knows and applies coding rules, guidelines, and accepted standards of coding and clinical documentation improvement practice.  Keeps current, learns and applies coding updates and changes.  Utilizes advanced knowledge of disease processes, medications, clinical indicators, and all parts of the medical record.  Makes and accepts data driven decisions, measures, and metrics.  Apply critical thinking, problem solving, and advanced CDI expertise. Analyze documentation, utilize algorithms, encoders, methodologies, and models, identify documentation gaps and opportunities, query, communicate, and achieve documentation outcomes.  Approach improvements and goals with open mindedness and offer help, ideas, solutions, and options. Is open to new approaches and alternative practices that will help meet institutional goals and objectives.  Listens to understand and is open to other’s ideas and suggestions.

 

Other duties as assigned

WORKING CONDITIONS

 

Frequency

Deadlines
Traveling
Physical Proximity
Sedentary Environment

Please Select
Frequent 34-66%
Constant 67-100%
Frequent 34-66%

 

PHYSICAL DEMANDS

 

Frequency

Weight

Keyboarding
Sitting
Standing
Walking
Carrying
Lifting
Pushing/Pulling

Constant 67-100%
Frequent 34-66%
Frequent 34-66%
Frequent 34-66%
Frequent 34-66%
Frequent 34-66%
Frequent 34-66%

Please Select
Please Select
Please Select
Please Select
10-20 lbs
10-20 lbs
10-20 lbs

 

COGNITIVE DEMANDS

Attention to detail
Multitasking
Working Alone
Interpersonal Skills
Written Communication

 

 

EDUCATION: Bachelor's degree in Nursing or Health Information Management.

EXPERIENCE:Five years of clinical coding or nursing experience in acute care facility. May substitute required degree with additional years of experience on a one to one basis.

LICENSURE/CERTIFICATION: One of the following: Certified Coding Specialist (CCS) from the American Health Information Management Association (AHIMA).Certified Professional Coder (CPC) by the American Academy of Professional Coders. Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA). Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA). Required: Current State of Texas Professional Nursing License (RN)Current State of Texas Professional Nursing license (RN). Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification. Preferred: American Heart Association Basic Life Support (BLS), ACLS (Advanced Cardiac Life Support) or PALS (Pediatric Advanced Life Support) certification as required by patient care area. Must pass pre-employment skills test as required and administered by Human Resources.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html

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