OUR GROWTH IS CREATING PROMISING FUTURES.
With the recent opening of Centegra Hospital-Huntley, fresh and progressive opportunities are dawning for patients and health care providers in McHenry County. As the second health system in Illinois to receive Magnet® status, the newest addition to the Centegra family of hospitals has created growth-friendly openings throughout our system. If you seek a career where your professional development is a shared priority between you and your employer, we encourage you to explore a future with Centegra.
CLINICAL DOCUMENTATION SPECIALIST
Positions will be located in Woodstock and McHenry
Full-Time Days: Varying start/end times
The professional we select for this vital role will facilitate the overall quality, completeness, and accuracy of medical record documentation to capture severity, acuity, and risk of mortality. As part of a multidisciplinary team, this individual will collaborate with medical staff to perform concurrent and/or retrospective reviews of patient health records to evaluate the integrity of clinical/patient-care documentation, and rely upon his or her expertise in understanding the clinical documentation required. Additional responsibilities include the following:
- Performing clinical documentation improvement (CDI) chart reviews (concurrent, pre-bill, and retrospective).
- Facilitating modifications to clinical documentation through extensive interaction with physicians, nurses, Clinical Effectiveness, Care Coordination, Health Information Management (HIM) coders, and other caregivers.
- Monitoring the accuracy/completeness of clinical information used to measure/report physician health system outcomes.
- Communicating with members of the patient-care team regarding clinical documentation improvement strategies and workflows.
- Ensuring that present on admission (POA) indicators are verified and clearly documented for coding while the patient remains in-house.
- Offering clinical assistance to coding associates in the identification of diagnoses affecting severity of illness (SOI) and risk of mortality (ROM) indicators.
- Collaborating with Clinical Effectiveness and Care Coordination to identify/address issues and improve quality indicators related to hospital acquired conditions (HACs), patient-safety indicators (PSIs), hierarchical condition categories (HCCs).
- Assisting with training of physicians and stakeholders on clinical documentation-improvement tactics.
- Facilitating the accuracy and compliance of coding assignments, LOS designation, POA status, HAC, and quality-of-care support for system initiatives.
- Assisting HIM in meeting time requirements for coding and billing revenue cycle.
- Current licensure as an RN and/or RHIA in the state of Illinois.
- CDI experience.
- Three or more years of inpatient clinical or coding experience.
- Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS).
- Strong clinical knowledge and demonstrated commitment to maintaining professional relevance.
- Familiarity with ICD-10 coding guidelines.
- General knowledge of what constitutes a complete and accurate medical record.
- Practical knowledge of official physician E&M guidelines and documentation requirements related to E&M assignment and establishment of medical necessity.
- Ability and willingness to communicate the benefits of complete and accurate documentation to physicians in the practice of medicine.
- Ability to obtain documentation relevant to denials avoidance related to the recovery audit program, the Comprehensive Error Rate Testing (CERT) program, and others.
- Ability to work with all physician specialties in clinical documentation-improvement initiatives, and tailor educational opportunities to each as needed.
- Ability to collaborate with case managers to capture patient severity of illness and intensity of service to ensure medical necessity.
- Working knowledge of the readmission reduction program, value-based purchasing, and coding principles.
- Excellent clinical judgment and medical decision-making abilities.
- CCDS, CDIP, and/or CCS.
- Two or more years of experience as a clinical documentation improvement specialist.
- Graduation from a school of nursing with a BSN.
- Graduation from an accredited health information management coding program.
- Familiarity with coding classification systems, including but not limited to APR-DRG and HCC.
- Proficiency with the electronic medical record and computers, including basic Excel and Word.
To explore additional career opportunities and apply visit centegra.org