Responsibilities
- 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 strategies, opportunities and specific clarification requests.
- 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 through the query process.
- 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
Requirements
- Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study or equivalent combination of education and experience
- Five (5) years of progressively responsible and directly related inpatient clinical experience
- 0 – 2 years of CDI related work experience
- Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred
Nice to Have
- ICU/ED and Academic Medical Center experience
- Case management, utilization review and/or direct provider interaction experience
Additional Information
- C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions.
- Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment.
- People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply.
- Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
