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A Brief Overview
Facilitates and obtains appropriate physician documentation while patients are in-house for clinical conditions and procedures to support the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Exhibits sufficient knowledge of clinical documentation requirements. APR-DRG assignment and clinical conditions and procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing and case management.

Essential Functions

Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principle diagnosis, pertinent secondary diagnoses and procedures for accurate APR-DRG assignment, risk of mortality and severity of illness. Conducts follow-up reviews of patients every 2-3 days as necessary, to support and assign a working or final APR-DRG assignment upon patient discharge.
Queries physicians regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, when needed. Collaborates with case managers, nursing staff and other ancillary staff regarding interactions with physicians on documentation and to resolve physician queries prior to patient discharge,m and follow up after discharge.
Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final APR-DRG, severity of illness and/or risk of mortality. Assists in the appeals process resulting from third-party reviews.
Educates physicians and key health care providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Facilitates change processes required to capture needed documentation, such as forms redesign and provider templates.
Participates in steering committee meetings.

Education Qualifications

Associate's Degree In HIM or Nursing Required or
Bachelor's Degree In HIM or Nursing Preferred

Experience Qualifications

1-3 years Coding or Pediatric nursing Preferred

Skills and Abilities

Clinical knowledge relevant to an acute care setting (Medium proficiency)
Coding skills with experience in ICD-10 and Knowledge of APR-DRGs (Medium proficiency)
Interpersonal skills effective with all levels of organization (High proficiency)
Proficient computer skills (High proficiency)
Ability to organize and prioritize appropriately (High proficiency)

Licenses and Certifications

CDIP - Clinical Documentation Improvement Professional within 1 Year Required and
CCS-Certified Coding Specialist Preferred or
RHIT - Registered Health Information Technician Preferred or
CPN - Certified Pediatric Nurse Preferred

Childrens is the very best for kids and the very best for your career! At Childrens, we put YOU first so together, we can improve the life of every child!