Demonstrates Competency in the Following Areas

• Maintains hospital daily census.
• Processes hospital statistics on a daily basis, meeting established deadlines.
• Forwards monthly statistical reports to specific departments, administration and the director by the 10th day of each month.
• Maintains death log.
• Abstracts ongoing blood audit medical records for Pathology and Performance Improvement departments, meeting established deadlines.
• Prepares medical records for performance improvement studies and service committees, meeting established deadlines.
• Assures that medical records are abstracted within three (3) days of patient’s discharge.
• Pulls requested medical records within time specified. Abstracts information from medical records by keying the information into the computer census abstract system, maintaining a 100% accuracy rate.
• Assumes responsibility for cross-checking quality, accuracy and completeness of abstracts.
• Assists in answering the telephones and taking accurate messages.
• Assists in retrieving medical records for physician completion, when necessary.
• Performs performance improvement functions through data collection and documentation review.
• Is familiar with pediatric and SNF medical record requirements.
• Maintains hospital requirements, policies and standards on confidentiality.
• Willingly accepts additional assignments.
• Supports and maintains a culture of safety and quality.
• Maintains a good working relationship within the department and other departments.
• Understands and is able to incorporate hospital philosophies into the department’s operational plan and goals, and assures staff members understand philosophies
• Demonstrates expertise in the clinical documentation, serving as a resource, and participates in problem-solving opportunities.
• Contributes ongoing department information, sharing and promoting knowledge and skill development.
• Comprehends and adheres to industry standards and regulatory requirements: including, but not limited to, TJC, HFAP, CMS, local regulations, HIPAA, medical staff regulations, and hospital policies.
• Demonstrates knowledge of resource management plans in an effort to decrease resource consumption, while adequately maintaining effective operations.
• Demonstrates working knowledge of information systems related to job duties.
• Possesses an awareness of reimbursement processes, including how different payers use the coded data to determine reimbursement. Aware of Medicare reimbursement methodology for inpatient services as it pertains to clinical documentation and coding.
• Possesses an awareness of hospital processes, understanding inter-department relationships, promoting collaborative effort and consideration prior to instituting changes, deletions or additions of processes.
• Proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, coding and audit tracking.
• Reviews inpatient medical records for identified payor populations (i.e., Medicare, etc.) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Ensures that clinical documentation reflects the level of service rendered to patients is complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services
• Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff
• Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 24 hours of admission, on the working days.
• Manages the concurrent medical record review for clinical documentation improvement
throughout the hospital. Identifies physician documentation
• issues/omissions/discrepancies and assists physicians with improving documentation in
the medical record.
• Regularly participates in scheduled case management and hospitalist meetings and actively exchanges information pertaining to clinical documentation, plan of care affecting coding and reimbursement.
• Maintains up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases.
• Assists in the development of diagnosis/DRG specific queries to aid physicians with proper and precise documentation.
• Facilitates the appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient’s past medical history of conditions is appropriately documented.
• Effectively utilizes documentation improvement communication tools
• Utilizes the encoder software to determine the working DRG and communicates daily with the HIM coding staff.
• Resolves inconsistent, conflicting and/or ambiguous documentation through the physician query process.
• Follows up with the physicians to get resolution of all queries prior to patient’s discharge.
• Takes responsibility and assists coders in follow-up on queries and clarifications to physicians done retrospectively post patient discharge.
• Performs audits on the encoder software in order to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process
• Works with health information management coding staff, physicians and financial services with regards to payment denials, medical necessity and documentation issues.
• Instructs staff on proper documentation in the medical record.
• Reviews audit inpatient claims with medical necessity denials looking for patterns by service or by the ordering physician. Follow-up in improving clinical documentation to reduce such denials.
• Maintains detailed Case Mix Index (CMI) reports for performance evaluation of CDI process.
• Maintains DRG assignment mismatch report of differences in DRG assignment by CDS and coders and provides feed back to supervising the Manager or Director for performance evaluation of CDI process.
• On an ongoing basis educates all members of the patient care team on documentation guidelines.
• Develops educational materials to inform Medical Staff and Nursing Staff regarding to update on the clinical documentation requirements.
• Actively participates and assists Performance Improvement Department in improving clinical documentation for compliance in quality of care measures (esp. Medicare
• CORE Measures) for specific charts
• Performs all other duties as assigned or required.
• Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them.
• Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives.
• Accepts constructive criticism in a positive manner.
• Adheres to attendance and punctuality requirements per hospital policy. Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness.
• Uses time effectively and constructively. Does not abuse supplies, equipment, and service.
• Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks and other related policies).
• Understands and abides by all departmental policies and procedures and is knowledgeable and complies with federal, state, and local laws that govern business practices as well as all accreditation standards that apply to the position.
• Conducts business in an ethical and trustworthy manner at all times.
• Attends scheduled in-service and mandatory in-service. Communicates ideas to supervisor for a safer layout of equipment, tools, and/or processes.
• Follows standard precautions and transmission based precautions.
• Adheres to procedure for proper disposal of medical sharps, pharmaceutical and medical waste per hospital policy.
• Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses.
• Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes
• Active participant in Continuous Quality Improvement program by assisting in finding new and better ways of performing duties and responsibilities.
• Understands performance improvement concepts and demonstrates understanding by:
• Defining performance improvement, and verbalizing at least one major goal of the performance improvement program within the hospital setting.
• Able to verbalize at least one departmental or hospital wide improvement initiative that has occurred within the last 12 months

Regulatory Requirements

• High School graduate or equivalent.
• One (1) or more years of similar previous hospital experience.
• Medical Graduate, PA or Nursing Graduate is required.
• Must meet the performance standard set forth by the Hospital/ Department at CDS position for at least 6 months.
• Please note that in order to be promoted to CDS II position; the Employee must meet certain performance standards as defined by the Hospital/ Department.
• ECFMG Certificate preferred.
• Minimum of 1+ year’s clinical experience in an acute care setting.
• Prior Case Management experience is desirable.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
• Excellent written and verbal communication skills. Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Working knowledge of Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current; preferred.