This position is responsible for reviewing content of the medical record and assisting in the clarification of any documentation ambiguities noted. This position is a member of the clinical team and acts as a consultant/subject matter expert to facility staff/providers related to medical record clinical documentation requirement to ensure the overall completeness, compliance and specificity of physician documentation exists. This position is responsible for identifying and capturing additional revenue opportunities and will also be the documentation liaison for the facility between coding and physicians.
Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between coding and physicians to explain, educate and assist in the needed documentation requirements to accurate conversion from the clinical language to the needed coding language in order to capture revenue.
Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible documentation clarification questions for members of the clinical team aimed at improving the accuracy of the documentation process which is followed by effective and appropriate communication with physicians and timely follow up on all cases.
Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which include but is not limited to, accurate input of case data, correct assignment of documentation clarification types and provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and facility outcomes (coding assignments, HAC, quality of care, facility and system initiatives) while facilitating HIMS dept compliance of time requirements for coding and billing revenue cycle.
Educates customers and creates presentations and/or reports for clinicians and facility management on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
Serves as member of facility task force meetings, and as requested attends facility steering committee meetings and/or other facility meetings.
Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelors degree in nursing, healthcare or related field.
Requires RN licensure in the state of practice or equivalent clinical knowledge. RNs must possess licensure. Exceptions: Verification of graduation from a foreign medical school (Doctor of Medicine degree).
Requires a proficiency level typically attained with 2-4 years acute-care, inpatient hospital, clinical experience. Must have the ability to work independently, possess demonstrated critical thinking skills, problem-solving abilities, effective communication skills and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.
Must pass a written clinical competency examination with minimum score of 70.
Experience with clinical documentation programs, use of electronic health record and coding preferred.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.
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