Req#: R14576
Category(s): Information Technology/Health Information Management, Medical Coding
Full Time / Part Time: Full-Time
Shift: First

Summary: 

The Clinical Documentation Specialist – Retrospective reviewer, collaborates with coding compliance and the department of healthcare quality in retrospective review of qualified selected cases. The employee as a acts as a liaison between medical staff, Nursing, Coding and QI specialist to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided.

Job Responsibilities: 

1) Provides clinically based retrospective review of inpatient medical records to assess and procure accurate and complete documentation of the patients' diagnoses and procedures.

2) Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.

3) Contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation.

4) Identifies opportunities to improve documentation and coding workflow process. Collaborates with the HIM management and staff.

5) Prepares and presents educational sessions to physicians on proper documentation.

6) Monitors and participates in performance improvement initiatives.

7) Participates in the planning for assigned inter/intra departmental meetings and presentations.

8) Participates in professional development and activities to keep current with trends in coding. This can include offsite meetings/conferences/site visits where travel and overnight stay might be required.

9) Communicates effectively and adaptable to a wide variety of interpersonal environments within the entire healthcare system. Able to be an approachable liaison to facilitate the achievement of CDI goals.

10) All tasks need to be performed following the Operating Principles of Baystate Health. Adheres to system and department compliance policies, and any and all applicable laws and regulations.

Education:

Associates degree or higher, graduate of a nursing or physician training program.

Required Work Experience: 

1) 5 years in an acute care setting; CDI and/or Facility Coding

2)  May consider Physician Trained experience

Preferred Work Experience: 

1) Familiar with CIS, MS Office

Skills and Competencies: 

1) Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Diploma in Nursing: Anatomy (Required)

Certifications:

Certified Clinical Documentation Special – Other, Certified Coding Specialist – American Health Information Management Association, Registered Health Information Associate – American Health Information Management Association, Registered Health Information Technician – American Health Information Management Association, Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

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