About this role
Join Precyse as we lead the movement toward HIM Innovation! Our clients will look to your expertise as you facilitate the improvement in the overall quality and completeness of medical record documentation. Precyse’s comprehensive Clinical Documentation Improvement and education platforms can be tailored to address specific hospital documentation improvement goals. This includes customized improvement programs and educational tools to meet those goals, including integrating ICD-10 principles and demands for further documentation specificity. Our three-phased CDI approach includes Assessment and Design, Education and Implementation, Follow-up and Monitoring. Our CDI Specialists have this wide array of tools available to them to ensure proper documentation and the achievement our clients’ long term goals.
Responsibilities:
Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Facilitate appropriate clinical documentation to ensure that level of services and acuity of accurately reflected in the medical record.
Use your extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.
Process discharges by updating the Severity/Complexity of Services Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis.
Educate internal staff on clinical documentation guidelines and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. Reviews clinical issues with the coding staff to assign a working DRG.
Participate in patient care conference/case conferences to identify needs for clinical documentation.
Generate accurate reports for the client upon the close of each phase of an engagement.
Company:
Precyse
Qualifications:
Desired Skills and Experience
RN, CCDS or CDIP a plus
Associate’s Degree in a relevant field preferred or combination of equivalent education and experience
Three plus years’ clinically well-rounded medical or surgical acute care nursing experience preferred
Critical care nursing experience preferred
Knowledge of clinical documentation guidelines and CDI program implementation experience preferred
Knowledge of medical terminology, ICD-9-CM and CPT-4 codes
Educational level:
Diploma
Level of experience (years):
Mid Career (2+ years of experience)
How to apply:
Please mention NLP People as a source when applying