2 jobs found in Lenexa

The Clinical Documentation Specialist (CDS) will review inpatient medical records as directed on admission and throughout hospitalization for completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM). The CDS will ensure effective and appropriate communication with the attending physicians, residents, fellows, PAs and APNs either verbally or in written methodology to suggest additional and/or more specific documentation. The CDS works closely with the HIM coding staff to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. Responsibilities Responsible for concurrent review of the clinical documentation in the medical records and query of the medical staff and other care givers as necessary via prompters/verbal communication to obtain accurate and complete documentation which appropriately supports the severity of patient illness and risk of mortality. In collaboration with the physician, nurse, patient care coordinator, ancillary departments, and HIM coder, identifies and records principle diagnoses, secondary diagnoses, and procedures. Conducts initial concurrent review and ongoing re-review for all selected admissions to initiate the tracking process, document findings on the CDS worksheets, and identify other key pathway or quality indicators as appropriate. Utilizes clinical knowledge to identify need to clarify documentation in records, and utilizes strong commination skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the accurate patient’s severity of illness and risk of mortality. Utilizes monitoring tools to track the progress of the program, through interpretation of on-site reports, monitoring reports and data. Shares findings with identified staff. Identifies areas that need focuses review through report analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Reviews coder feedback on completed worksheets and individual CDS tracking system reports as a means of continuous self-evaluation; discusses any issues or concerns with the CDI Supervisor. Educates Physicians and Staff regarding severity of illness and risk of mortality documentation. Collaborates with Physicians, Mid-level Providers, CDI Staff, and HIM Coders as well as works directly with individuals and departments where documentation improvement opportunities exist. Coordinates data and documentation compliance and collaborates on all aspects of the program to improve clinical documentation. Serves as an effective communicator of the clinical documentation improvement program’s vision and goals. Expressed ideas clearly and effectively (gaining agreement and/or understanding), by adjusting language, terminology, and style to the characteristics and needs of the audience as well as the venue for the communication. Effectively administers training sessions to new House Staff, Attending Staff, Nursing and Ancillary personnel. Develops and participates in presentations on clinical documentation improvement. Demonstrates competence in the areas of critical thinking, interpersonal relationships and technical skills. Manages his/her organizational responsibilities in a way that supports the achievement of departmental goals. Works effectively with others in the management team to accomplish organizational goals and to identify and resolve problems. Skillfully administers, directs and allocates all organization resources. Uses appropriate interpersonal styles and methods to develop a unit/team-wide spirit and intra-team and inter-team cooperation. Ensures confidentiality of all data and security of Protected Health Information as it relates to HIPAA requirements. *Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department. *Note: These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required. Qualifications Required: Bachelor’s Degree in Nursing RN license in Kansas 3-5 years clinical experience in an acute care setting Will also accept foreign medical graduate (MD) with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license Preferred: Previous Clinical Documentation, Case Management or Critical Care experience

The Clinical Documentation Specialist (CDS) Lead will audit CDSs review of inpatient medical records for completeness and accuracy for query and coding accuracy. The CDS Lead will use data to evaluate and educate attending physicians, residents, fellows, PAs and APNs to suggest additional and/or more specific documentation in support of the CDI program. The CDS Lead will work closely with the CDS Manager and Coding Supervisor to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. The Lead will also use data for auditing to support and provide completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM). Responsibilities Demonstrates ability to provide service safely and efficiently for the care of each patient. Provides effective leadership to the Clinical Documentation Specialist team. Able to strategically identify, internalize and communicate the critical success factors necessary for the department. Serves as an effective communicator of the Health Information Management Clinical Documentation Specialists vision and goals; expresses ideas clearly and effectively (gaining agreement and/or understanding), by adjusting language, terminology and style to the characteristics and needs of the audience as well as the venue for the communication. Manages his/her organizational responsibilities in a way that supports the achievement of departmental goals. Works effectively with others in the Clinical Documentation Specialist team to accomplish organizational goals and to identify and resolve problems. Skillfully administers, directs and allocates all organizational resources. Demonstrates personal effectiveness in supporting the department/section towards it goals; models appropriate values and maintains and promotes social, ethical and organizational norms. Creates and communicates the "big picture" understanding of the hospital and works to ensure the department supports the organization's desired competitive position. Uses appropriate interpersonal styles and methods to develop a unit/team-wide spirit and intra-team and inter-team cooperation. Stays focused on all key stakeholders and supports the unit/team ability to deliver on all valid stakeholder expectations. Supports all the Clinical Documentation Specialists on chart queries, new employee orientation, educational sessions, daily processes to include all initial and retrospective chart reviews, or any special assigned tasks; ensures optimal workflow in meeting established goals/timeframes. Provides education to all physicians, mid-level providers, nursing staff, etc. to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality. Reviews the progress of the documentation review program, through interpretation of monitoring reports and data; must be able to work collaboratively with the CDI Manager to identify areas of focus through report analysis. Performs initial and retrospective chart reviews, sends queries and completes the special tasks as assigned. *Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department. *Note: These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required. Qualifications Required : Bachelor’s degree in Nursing Three (3) years’ experience in an acute care setting Must have a current RN license in Kansas for RN's Will also accept foreign medical graduate (MD) with CDI certification of CCDS and/or CDIP in lieu of Kansas RN license. 18 months of experience in Clinical Documentation Improvement (CDI) Superior oral and written communication skills Preferred : CDI certification of CCDS and/or CDIP