Clinical Documentation Improvement Coordinator
LOCATION: WICKENBURG, AZ
Wickenburg Community Hospital is a beautiful and sophisticated rural-access hospital located in Wickenburg, Arizona. WCH is a 19-bed Emergency Department and many ancillary services. We also have 3 Primary Care Clinics. Here at WCH, we strive to maintain the highest standards of professionalism and care. Join us today and let us be part of your success story.
- Full Benefits
- PTO/Sick Leave
- Wellness Benefits
The Clinical Documentation Improvement Coordinator collaborates extensively with physicians, nursing staff, coding staff and billing staff to improve the quality and completeness of documentation of care provided at our hospital and clinics. Queries and educates medical staff. Conducts focused chart reviews and documentation audits. Monitors provider quality performance and works with providers to improve documentation to meet measure goals.
Essential Job Duties
- Responsible for compliance with CMS Conditions of Participation regarding Utilization Review.
- Build and generate reports from the EMR. Review medical record for compliance including completeness and accuracy for severity of illness and quality.
- Complete accurate and timely record review to ensure the integrity of documentation compliance. Understands and supports documentation strategies related to EMR and continues to educate self and revenue cycle team members.
- Perform random ED Nurse audits utilizing current template and report results to ED Director.
- Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.
- Strategically educate members of the patient care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing and care management. This includes compliance updates from Medicare.
- Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions.
- Follow up with doctors and nurses where needed to complete individual patient’s records
- Track and report unlocked charts
- Complete well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
- Will stay abreast of the regulations regarding documentation requirements and actively engage in continuing education and training WCH staff accordingly.
- Track length of stay outliers (Observation > 48 hours, Inpatient > 96 hours and Inpatient < 48 hours).
- Track readmissions within 30 days.
- Perform MCG admission determinations during working hours. Set up new employees with MCG access and assist with training.
- Track and report missing/inaccurate MCG determinations
- Perform Acute Unit concurrent reviews daily for Observation patients and every other day for Inpatient patients.
- Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patients medical records.
- Attend Acute Unit huddle Mon-Fri and discuss ongoing patient needs and discharge readiness.
- Refers to Compliance Officer and hospitalist cases that do not meet established guidelines for admission or continued stay.
- Assists the UR Committee in the assessment and resolution of utilization review problems.
- Identifies problems related to the quality of patient care and refers them to the Quality Assurance nurse and enters a report in SQSS.
- Maintains communication with case management/social services to facilitate timely discharge planning.
- Compiles monthly reports and statistics for presentation to the UR committee.
- Collaborates with patient access regarding denials and facilitates peer reviews as needed.
Other (Non-Essential) Job Duties
- Actively participate in meetings, including presentations for educational opportunities.
- Will participate in various committees across the organization such as peer review committee, ED steering committee and utilization review committee.
- All other duties as assigned
- Coding certification from either AHIMA or AAPC.
- Prior experience in CDI, UR/UM, discharge planning, quality management, case management or coding.
- Advanced computer skills and spreadsheet utilization.
- Excellent written and verbal communication skills.
- Demonstrates basic knowledge regarding HIM coding standards.
- Analytic skills necessary to accurately assess patient medical records.
- Excellent interpersonal skills and ability to work on a team to influence change.
- Certification in clinical documentation through either AAPC or AHIMA, or ability to obtain within 1 year of hire.
- RN or BSN preferred.
- 3-5 years recent experience in an acute care hospital setting preferred.
Physical Requirements / Working Conditions
- Must be able to sit for long periods
- Must be able to operate standard office equipment
- Must be able to lift and carry up to 20 lbs
- Must be able to work paying close attention to detail with frequent interruptions.
- Ability to work in a fast pace environment.
- Adequate hearing and vision for effective communication.
- Follow complex instructions.
- Think logically in following procedures and instructions.
- Work well under stress, with interruptions and deadlines.
- Effectively communicate dept needs to other departments.
Job Status: Full Time