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Penn Medicine, University of Pennsylvania Health System · 1 month ago

HIM Clinical Documentation Specialist

Philadelphia, PA

Part-time

Onsite

Mid Level

3+ years exp

Penn Medicine is dedicated to providing the highest level of care to patients and conducting innovative research. The Clinical Documentation Specialist will support the organization-wide system for improving clinical documentation by educating clinical teams and ensuring accurate documentation in compliance with CMS coding guidelines.

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Responsibilities

Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines

Provide clinical care teams with ongoing education and training on current trends in documentation and coding

Enter clinical review data and related anticipated follow-up in EPIC PENN Chart to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG

Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity

Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system

Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes

Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation

Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation

Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed

Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation

Proficient in negotiating complex systems to effect positive change

Ability to interpret, adapt, and apply guidelines and procedures

Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems

Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding

Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary

Serve as a resource on DRG issues

Qualification

Clinical DocumentationCoding GuidelinesHIPAA ComplianceEPIC PENN ChartDRG AssignmentHealthcare ExperienceProfessional DevelopmentCritical ThinkingCommunication SkillsNegotiation Skills

Required

Bachelor of Arts or Science

3+ years healthcare experience

Extensive knowledge of reimbursement systems

Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding

Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems

Ability to analyze complex clinical scenarios and apply critical thinking

Ability to interpret, adapt, and apply guidelines and procedures

Proficient in negotiating complex systems to effect positive change

Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed

Direct review of patient charts to audit clarity and full reflection of severity in care team documentation with consideration of CMS coding guidelines

Provide clinical care teams with ongoing education and training on current trends in documentation and coding

Enter clinical review data and related anticipated follow-up in EPIC PENN Chart

Generate compliant queries and non-leading clinical conversation regarding requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity

Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service

Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes

Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation

Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation

Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation

Preferred

RHIA or RN

CCDS or CDIP or RN

Master of Arts or Science

Clinical experience with knowledge of Medicare reimbursement system & coding structures

Benefits

Comprehensive compensation and benefits program

Prepaid tuition assistance programs

Company

Penn Medicine, University of Pennsylvania Health System

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Penn Medicine is a world leader in academic medicine, setting the standard for cutting-edge research, compassionate patient care, and the education of future health care professionals.

Founded in 1765

Philadelphia, Pennsylvania, USA

10001+ employees