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RN - Clinical Documentation and Compliance Specialist
Presbyterian Healthcare Services
Remote, USA
Full-time
Entry · 2+ years experience
Remote
USD 65520-111612.8 yearly / year
Discovered 1 months ago
ICD-10CPTHCPCSDRGAPC
Key Skills for This Role
ICD-10CPTHCPCSDRGAPC
Full Job Posting
Responsibilities
- Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions and documents findings.
- Works collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile.
- Assist physicians with documentation requirements to support medical necessity for hospital and physician billing.
- Interprets clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary, for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate.
- Initiates communication to physicians, providers, verbally or utilizing the appropriate prompter/query tools, in order to obtain more specific principal diagnosis or co morbidities and complications. Solicit clarification of existing documentation in the medical record that support patient severity of illness.
- Acts as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
- Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation.
- Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
- Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-10, CPT, HCPCS and APC updates and changes. This includes but is not limited to CMS, JCAHO, Nursing Standards of Practice, etc.
Qualifications
- All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
- Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
- Why work at Presbyterian? As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
- About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
- Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
- AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
About Presbyterian Healthcare Services
Hospitals & Health Systems14000 employeesFounded 1908
Improving the health of patients, members, and communities.
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