Clinical Documentation Integrity Specialist I

Prisma Health
United States, South Carolina, Columbia
Nov 13, 2024
Inspire health. Serve with compassion. Be the difference. Job Summary Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of provider documentation. This is accomplished by medical record review, query process, and reconciliation process. Responsible for assisting in maintaining a financially healthy, productive department, and promoting their own development with an emphasis on evidence-based practice education. Accountabilities Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation. (60%) Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (25%) Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%) Develop and maintain supportive, collaborative relationships with providers and health care team members to include education and follow up. (2%) Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies. (1%) Serve as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.) (1%) Assign a working DRG for health care team discharge planning and CDI use. (1%) Performs other duties as assigne Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive. Minimum Requirements Associate degree - Nursing, Health Information Management, or related field 2 years - Adult medical/surgical/critical care/ER/PACU nursing coding or related field In Lieu Of In Lieu of the education and experience requirements noted above, the following combination of education, training and/or experience will be considered an equivalent substitution: MD/DO/PA/NP Required Certifications, Registrations, Licenses RN/RHIA/RHIT/CCS/CIC/Licensure in related field Knowledge, Skills and Abilities Computer skills, keyboarding. Strong communication skills with ability to interact with providers and remain tactful. General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems. Preferred Work Shift Day (United States of America) Location Corporate Facility 7001 Corporate Department 70017540 Clinical Documentation Integrity Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.