Job Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
Entity: Corporate Services
Department: Corp HIM CDI
Location: 1500 Market Street
Hours: M-F 8a-4:30p, Remote
The Health Information Management (HIM) Clinical Documentation Specialist will oversee organization-wide system for improving clinical documentation in the medical record. Plan, organize, design, implement and monitor coding initiatives to improve coding quality and reimbursement. Provide individual and group education to Coding staff, Clinical Documentation Improvement (CDI) Specialists, Providers and others throughout the organization that requires coding and documentation knowledge. Assist Coding Management staff in performing quality audits on coding staff and assist with management of the provider query process. Provide back up as necessary for reviews related to departmental and health system quality initiatives. Process clinical validation denials by disputing payer payment reductions when appropriate through identification of supportive documentation, clinical indicators, and treatment noted in the patient's encounter with a strong foundation in payer criteria and established clinical definitions. Develop and maintain data, quality metrics and dashboards for Leadership.
Accountabilities
Ensure that inpatient clinical documentation accurately reflects severity of illness and intensity of service
Ensure that present on admission (POA) clinical conditions are charted appropriately within defined regulatory timeframes
Communicate with Physician or designee requesting appropriate recommendations for documentation improvement
Perform targeted chart reviews using various of risk adjustment methodologies to facilitate accurate reporting of mortality statistics
Perform chart reviews to reflect accurate safety rating scores and quality of care statistics
Assist HIM Coding Quality team with clinical validation audits and provide support for coding quality initiatives
Active participation in team meetings and educational presentations to CDI Specialists, Coders, various Physician groups and others on specific documentation improvement topics
Process clinical validation payer denials utilizing payer-specific criteria, established definitions, and assessment of chart documentation
Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
Other duties as assigned to support the unit, department, entity, and health system organization
Minimum Requirements
Required Education and Experience
Bachelor's Degree in Nursing, Health Information Management or related field is required. (Master's preferred)
5+ years of Clinical experience in Nursing and/or HIM or related field.
1+ years of Clinical Documentation Improvement (CDI) Specialist and/or coding quality experience
1+ years of CCU/ICU acute care clinical experience
Licenses, Registrations, and Certifications
Current PA licensed RN, RHIA, RHIT or CCS
Required Skills and Abilities
Strong knowledge of MS-DRG's and medical record documentation requirements are essential
Ability to analyze complex clinical scenarios and apply critical thinking
Possess basic computer skills in word processing and spreadsheet utilization
Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
Ability to interpret, adapt, and apply guidelines and procedures
Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
High level of creativity, judgment, and initiative, tempered with flexibility to deal with a rapidly changing healthcare environment and expanding technology
Self-motivated, well-organized, and possess excellent communication and analytical skills, as well as, strong facilitation and presentation/education skills required
Ability to maintain concentration with attention to detail.
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. Pennsylvania Medicine
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