About this role
Role Overview
- Provide timely reviews of patient medical records to ensure accurate and complete documentation
- Work with providers and coders to ensure documentation reflects the complexity of the patient
- Ensures inpatient clinical documentation accurately reflects severity of illness (SOI) and Risk of Mortality (ROM)
- Ensures Present on Admission (POA) clinical conditions are documented accurately
- Ensures documentation reflects accurate safety rating scores and quality of care scores (PSIs)
- Participate in education sessions and feedback to coders, CDI Reviewers, and Hospital Quality Departments
- Conduct regular audits using standardized methodology to ensure compliance
- Tracks and trends data for use by the HIM Documentation Quality and Education Manager
- Escalates any observed issues which may impact quality of documentation or coding
- Ensures that coding and DRG assignment is in compliance with CMS rules and regulations
Requirements
- RN with BSN required
- 3+ years of clinical documentation experience
- CCDS or CDIP certification
- Must have CCS (AHIMA Credential) or take steps to obtain CCS within 90 days of hire
- Strong clinical training experience
- Second Level Review experience
- 5+ years of acute care experience required
- Strong analytical skills to clinically evaluate the medical record
- Ability to use a PC for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
- Ability to communicate effectively with e4health management and clients
Benefits
- excellent salary
- full benefits package including 401(k) with company match
- medical insurance
- dental insurance
- vision insurance
- life insurance
- short/long term disability insurance
- PTO policy