 Clinical Documentation ConsultantDepartment: NCAL Rev Cycle HIM
Schedule: Full-time, Regular, 40 hours per week, Day shift,
Position Summary:
This position uses clinical knowledge and knowledge of coded data for documentation requirements to improve overall patient quality, capture severity, acuity and risk of mortality. In addition to have expertise in understanding the clinical documentation required for the completeness of the patient records using a multidisciplinary team process.
Education/Licensure/Certification:
Graduate from an accredited school of nursing (BSN required). Current licensure to practice as a Registered Nurse in the State of California and Non-CA. Or Graduate from an accredited RHIA or RHIT program (AA or BS/BA required); Or Medical Doctor license outside/inside the US.
Qualifications:
Minimum of 3-5 years clinical experience (i.e. inpatient, clinical documentation, discharge planning, case management.
Strong interpersonal, communication (verbal, non-verbal, and listening skills). Understand Adult Learning Theory. Competent computer skills including word processing, spreadsheets, and presentation software. Must have strong analytical skills. Understand coding classifications systems such as, but not limited to ICD-9 CM, Current Procedural Terminology (CPT), Healthcare Common Procedural Coding (HCPCS), MS-DRG, HCC strongly preferred.
Demonstrated ability to conduct and interpret quantitative/qualitative analysis. Proven leadership skills in project management and consulting. Must exhibit efficiency, collaboration, candor, openness, and results orientation
Demonstrate an understanding of the operations and/or business of KP, health policy trends, and any applicable regulations related to the responsible practice area. Seasoned coders with clinical knowledge and experience with over 10+ years may also qualify.
Preferred Qualifications:
For HIM professional a certificate is required in one of the following: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Specialist – Physician (CCS-P) 8-10 years of inpatient coding experience, including MS-DRG, APR-DRG or similar methodology. Prior CDI experience preferred.
Duties:
Adheres to the hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships and team building. Establishes effective working relationships with the local and regional staff/teams/leadership. Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is recorded. Identifies and reviews primary and secondary diagnosis and complications to ensure diagnosis documentation and capture through addendums may identify patients who need to be seen. Identify and review for POA (Present on Admission) documentation. Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient.
Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc) to ensure complete and accurate diagnosis capture and coding. Collaborates in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Communicates information effectively with medical center leaders. Works with Coding Review Manager to develop, implement and monitor departmental policies and procedures that support organizational goals, business objectives, regulatory needs and requirements. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to leaders, local regional management and medical team. Queries medical staff for accurate clear documentation in the patients medical records. Monitor and track verbal and written queries and produce reports as required.
Consistently supports compliance and the Principles of Responsibility (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.
In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.
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