Job Function Summary:

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.

Generic Scope (not customizable, will not be used in the job posting/advertisement):

Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.

Custom Scope (customizable, will be used in the job posting/advertisement): 

Applies skills and experience as a seasoned clinical documentation specialist to projects of medium size at all levels of complexity, or portions of large projects.

Knowledge, Skills and AbilitiesReq / PrefThorough knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, co-morbidities, discharge, and other practices that are part of effective clinical care systems.ReqThorough understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes.ReqThorough knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.ReqDetail oriented, with proven organizational skills and the ability to effectively manage time, prioritize tasks, and see complex projects through to completion on schedule.ReqStrong critical-thinking and problem solving skills to manage multiple levels of information and responsibilities, and quickly assess complex problems to develop multiple potential solutions.ReqStrong interpersonal and educational skills, with the ability to ability to collaborate effectively with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues.ReqProven ability to interpret and effectively convey complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports.ReqStrong ability to work with senior staff and managers across departments and to provide advice and recommendations on complex issues of functionality, clinical quality, efficiency, and program development.ReqProven computer proficiency in relevant multiple technology applications.Req3 years related work experienceReq          

 

Education

Req / Pref

Bachelor's degree in PT/OT/SPTRequired      

%  

of time 

Essential Function (Yes/No) 

   

Key Responsibilities 

(To be completed by Supervisor) 

25% 

Yes 

Performs complex reviews of patients' medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM). 

10% 

Yes 

Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of CMG (case mix grouping) assignment. 

5% 

Yes 

Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient's condition, treatments, and any co-morbidities. Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews. 

25% 

Yes 

Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement. Recommends timely and effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance. 

5% 

Yes 

Monitors changes and updates in regulatory requirements for clinical documentation. Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements. 

10% 

Yes 

Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues. Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in-service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement. 

5% 

Yes 

Provides therapy and nursing educations on IRF annual changes 

5% 

Yes 

On boarding education on evaluation and scoring of IRF requirements 

5% 

Yes 

Partners with Apex to ensure documentation supports IRF regulations 

5% 

Yes 

Partners with physicians and medical director to provide education and feedback 

100% 

 

(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)