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POC CDI Nurse
Acclara Solutions, LLC
Location: Fort Washington, Pennsylvania
Work Setting: Non Provider Setting
Job Function: CDI Specialist
Job Type: Full-Time
Salary Range: 60,000-65,000
Under the direction of the Director of Coding the Point of Care-Clinical Documentation Improvement Nurse Specialist is responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and further translates the clinical information into a hospital-based coding system. Specifically, this position will have extensive knowledge of clinical medicine that allows for the valid translation of a patient’s clinical level of care, severity of illness, and services provided to the appropriate coding conventions and classification systems. These systems include ICD-10 CM/PCS, DRG and APR- DRG. This position is responsible for maintaining a daily unit census and production and quality standards as established by the client.
|REQUIRED JOB KNOWLEDGE & SKILLS:|
· The ability to communicate effectively and professionally with all levels of clinical and administrative personnel required.
|CORE RESPONSIBILITIES & JOB FUNCTIONS:|
|Core responsibilities include but are not limited to the items listed below:
· Maintains a daily unit coding census with the expert identification of clinical documentation improvement opportunities and accurate ICD-10 CM/PCS code assignments.
· Provide concurrent review of inpatient accounts including admission review and periodic updates based on analysis of all available clinical information in the patient’s record at a minimum production of 20 accounts per day with an accuracy rate of 95%.
· Review medical records for key words/phrases and tendencies in documentation to support specificity of diagnosis codes, procedures for appropriate/optimal reimbursement. Sequence diagnosis and procedure code assignment for appropriate/optimal DRG reimbursement as indicated by the Coding system.
· Records the information identified above and abstracts clinical information into the medical Coding system from the medical record following established standards, methods and procedures. Assigns a working DRG, case mix index and geometric LOS for review.
· Identifies and recommends any documentation opportunities that would support a more accurate assignment of the encounter working DRG, including severity of illness and geometric LOS. Effectively communicates all opportunities/recommendations in the
Coding system, verbal or via email to the clients’ onsite CDI and Coding Teams.
· Performs all responsibilities with the ability to adjust to multiple structures in a highly independent and professional manner consistent with the goals and core values of the company.
· Follow all HIPAA related procedures and rules ensuring the maintenance of patients’ PHI (Protected Health Information).
· Maintain compliance with the work rules and expectations established in the CDI remote work policy
Other duties as needed and assigned.
|EDUCATION & WORK EXPERIENCE:|
|BA/BS degree in a healthcare related field preferred or a minimum of AS degree in a healthcare related field required. Registered Nurse (RN) with active license with 3-5 years acute care inpatient experience. Successfully complete the clients CDI training program, EPIC and all related job performing training essentials with the expectation of developing a working knowledge of ICD-10-CM/PCS and willing to progress to an expert knowledge of the ICD-10CM coding conventions and the AHA Coding Clinic.
Posted: February 26, 2020 at 3:57 PM
Post ID: 48655