This position is responsible for consistent application of regulations governing patient rights and grievances, as well as receiving, handling and documenting feedback regarding the quality of care/services received at the Hospital.
- Supervises and manages daily operations of the Clinical Documentation Improvement (CDI) and clinical coding audit teams.
- Ensures compliant, accurate, coding through implementation of policies, procedures, and workflows within the CDI and Clinical Coding Audit teams.
- Implements and coordinates all activities within the scope of the HIMS Clinical Coding Auditing program to ensure compliance to regulatory requirements for clinical coding.
- Collaborates in education of Clinical Operations regarding specific documentation needs for appropriate reimbursement identified through concurrent and retrospective documentation reviews and clinical coding audits.
- Develops and recommends new or revised training goals and objectives to the HIMS and RCM Management teams based on trends in clinical coding and documentation.
- Prepares reports on HIMS CDI activities including trend analysis, Key Performance Indicators (KPIs), or other ad hoc reports for management or external agencies.
- Evaluates CDI effectiveness to develop improved methods; devises and implements evaluation methodology for CDI and clinical coding audits; analyzes results and recommends and/or takes appropriate action.
- Reviews regulatory and clinical coding best practices independently or in conjunction with the HIMS Management team to ensure that clinical coding and clinical documentation is compliant.
- Performs IR-DRG reviews with the Physician Liaison and provides feedback on review results to the Clinical Coding Manager and Coding Technicians.
- Manages the development of pertinent communications regarding clinical documentation and clinical coding for distribution such as newsletters, brochures or flyers; coordinates process from development through printing and distribution.
- Develops and facilitates workshops, meetings or conferences on documentation improvement and coordinates logistics, and scheduling related communications.
- Creates or revises training courses within the Learning Management System (LMS) when any new or revised policy, procedure, or workflow is released.
- Reports to and collaborates with Clinical Operations and Medical Informatics on clinical documentation improvement initiatives and present clinical coding trends for review with physicians and hospital leadership.
- Participates in internal education programs for Clinical Operations regarding regulatory requirements and guidelines for clinical documentation and clinical coding.
- Works with the EMR IT team to troubleshoot issues related to clinical documentation workflow.
- Oversees the implementation and utilization of the Computer Assisted Coding (CAC) software.
- Maintains confidentiality of the patient’s confidential health information (CHI) in both electronic and paper formats.
- Performs other duties and participates in special projects as assigned by the HIMS Management team.
- Minimum 3 years experience in a Health Information Management (HIMS) or Revenue Cycle Management (RCM) Department preferred.
- Minimum 3 years experience utilizing the ICD-9-CM or ICD-10 coding preferred
- Minimum 1 years experience utilizing the CPT 4 coding system. preferred
- Knowledge of on the job training techniques and mentoring principles preferred
- Skilled in the use of Microsoft Word, Excel, and Power Point to develop training materials, reports, and documents.
- Ability to work with audio and visual equipment in a classroom environment.
- Ability to work under pressures and deadlines.
- Excellent level of oral and written English.
- Bachelors in a healthcare related field or is preferred
- Graduate of a recognized clinical coding program preferred.
- Graduate of a clinical training program preferred
- Minimum of Associates of Science in Health Information Technology or Healthcare Management is required
- CCA, CCS, CPC, or CCS-P preferred.