Jobs for People with MS: National MS Society

Responsibilities Job Description

Performs concurrent inpatient chart reviews for documentation improvement opportunities. Communicates with physicians to ensure comprehensive medical record documentation to reflect clinical treatment and diagnose. Uses provided CDI software to identify opportunities, evaluate documentation, gather, and analyze information pertinent to findings and outcomes, formulate a DRG and confers with coders to ensure appropriate DRG assignment. This review process assures complete and accurate diagnostic and procedural coded data that supports compliant and accurate facility reimbursement, financial and strategic planning, outcome and statistical analyses, epidemiology/research work, and accurate reflection of patient mortality risk, severity of illness, quality of care, and patient safety measures.

• Completes daily concurrent reviews of the medical record to identify opportunities for clarification or improvement of the clinical documentation.

• Identifies diagnoses and procedures codes to assign an accurate working DRG.

• Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment.

• Creates and sends compliant queries to clarify and/or improve the provider’s documentation. Ensures the query verbiage is not leading or suggestive and is supported by the documentation in the record to include clinical indicators and treatment provided. Queries adhere to all coding and clinical documentation integrity guidelines as endorsed by ACDIS and AHIMA.

• Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies

• Promotes accurate DRG classification according to standards set forth by CMS (Center for Medicare & Medicaid Services) to reflect accuracy with DRG-based payers.

• Responsible for supporting and facilitating the overall quality of medical record documentation by clarifyingA key success factor of this process is providing ongoing provider education through the query process and supporting providers with feedback that accurately reflects the true clinical picture within the medical record.

• Carries out follow-up practices related to provider query responses per department policy.

• Confers with coders to ensure appropriate final DRG and completeness of supporting documentation. Coordinates with coding to reconcile DRG mismatches.

• Collects and reports on data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.

• Through chart review processes, ensures quality, patient safety indicators, present on admission indicators, risk of mortality, and severity of illness measures are clearly and accurately documented in the medical record.

Required

• Associates degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience

• 1 years Acute/Inpatient experience as an RN or 2 years of inpatient coding or CDI experience

• One of the following: RHIA, RHIT, RN

Preferred

• Bachelor’s degree (or higher) in Nursing or HIM or related field or equivalent experience.

• 5 years of acute/Inpatient care nursing or 5 years of inpatient coding or CDI experience

• One of the following: CDIS, CDIP, CDEI, CCDS, CCS, CPC, COC

Qualifications

$80100.80-$113068.80 / Annual

EEO Statement

EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information: https://www.fairview.org/careers/benefits/noncontract

Compensation Disclaimer

The posted pay range is for a 40-hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical.