DescriptionSHIFT: No Weekends
Clinical Documentation Specialist Full Time
Highlands Regional Medical Center
Highlands Regional Medical Center
Highlands Regional Medical Center, located in Sebring, FL is a 126-bed inpatient, full service facility offering a full range of Emergency, Surgical, Inpatient and Outpatient services. Highlands Regional Medical Center offers the most advanced technology and attracts the most highly qualified physicians and surgeons in our area. Serving the surrounding counties with all the expertise and compassion at its command, Highlands Regional Medical Center has cared for the citizens of Highlands and its surrounding counties since 1965. As we grow, the hospital is becoming more and more important to the people throughout this area.
Expertly staffed and equipped, this full-service hospital provides the proper environment essential for patient progress and ultimate recovery. Highlands Regional Medical Center's personnel, consisting of highly trained professionals, form a dedicated healthcare team whose coordinated efforts assure consistent excellence in various medical specialties. Highlands Regional's modern facility is designed to meet the diversity of its patients’ needs, from emergency care, to outpatient care, to surgery.
We offer a generous compensation package for Full-time and Part-time including: vacation, 401k, and Medical Insurance.
Reviews medical records and identifies potential gaps in clinical documentation for specified facilities, patient types and payer populations, as directed on admission and throughout the hospitalization. Performs initial concurrent review of assigned population consistent with Facility, Division, or Corporate program volume and frequency requirements. Performs follow-up reviews consistent with Facility, Division or Corporate program volume frequency requirements. Assigns working DRG based upon identification and selection of principal diagnosis, complications or co-morbid conditions and/or valid OR procedures, including capture of POA indicators. Ensures documented conditions, clarifications, and coded diagnoses are clinically supported. Documents reviews and other pertinent information in designated systems by established deadlines.
Uses clinical judgement to determine when and/or if a query is necessary. Queries physicians within established timelines via approved query forms for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate. Uses clinical judgement to determine appropriate and relevant clinical indicators and to discern appropriate reasonable diagnostic options when formulating non-standard queries. Interacts with Physicians to complete/resolve queries prior to patient discharge.
Collaborates with the Parallon HSC to assure accurate DRG assignment and billing. Performs reconciliation of CDI-assigned DRG against final coded DRG. Escalates DRG mismatches as appropriate per established protocols. Develops collaborative relationships to facilitate accomplishment of work goals. Possesses excellent interpersonal skills in building, negotiating, and maintaining crucial relationships. Demonstrates a willingness and ability to assist others.
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