September 17, 2024

Day Kimball Healthcare

Putnam

FULL TIME

Clinical Documentation Specialist ENSEMBLE

Clinical Documentation Specialist

*This position is onsite at Day Kimball Healthcare in Putnam, CT and candidate must be able to work FT onsite at this location. *

* Please note: this position is NOT a Day Kimball Hospital role and employment for this position is through ENSEMBLE*

Job Summary:

The CDI Specialist facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure to support the appropriate severity of illness, expected risk of mortality, and complexity of care as documented in patient medical records. Extensive medical record review and interaction with physicians, nursing staff, other patient care givers and HIM coding professionals is done to ensure the documentation is complete and accurate.

Job Responsibilities:

Completes initial patient medical record review within 24-48 hours of patient's admission; completes subsequent reviews of patient's medical record reviews every 24-48 hours and enters review findings in CDE software system.
Assigns Principal diagnosis, CC/MCC (complication and comorbidity/major complication and comorbidity), evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house. Assigns working ICD-10-CM and PCS codes and DRG (Diagnosis Related Group) using encoder in CDE software.
Clarifies with physicians regarding missing, unclear, unsupported or conflicting health record documentation by requesting and obtaining additional documentation from physicians when needed. Face to face physician interaction and written clarifications are used.
Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record.
Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment. Reviews DRG denial letters and writes denial appeal letters.
Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.

Maintains and upholds all clinical documentation regulatory guidelines

Formulates and submits timely, well prepared appeals for reconsideration by third party administrators (payors). Including supporting documented clinical evidence, Coding/CDE. Guidelines and other regulatory standards/guidelines as appropriate. Works collaboratively with co-works and management to effectively resolve root cause issues that impact payor contracts, hospital operations, or departmental to maintain reimbursement and minimize appeal requests and/or denials.

Experience We Love:

Minimum of five years acute care nursing experience with specific medical/surgical,
Intensive Care, or Emergency Department experience
Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations
Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills

Minimum Education

Current RN Licensure

Certifications:

CRCR Required within 9 months of hire

Ensemble Health Partners is an equal employment opportunity employer. It is our policy not to
discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender,
gender identity, religion, national origin, age, disability, military or veteran status, genetic information or
any other basis protected by applicable federal, state, or local laws. Ensemble Health Partners also
prohibits harassment of applicants or employees based on any of these protected categories.
Ensemble Health Partners provides reasonable accommodations to qualified individuals with disabilities in
accordance with the Americans with Disabilities Act and applicable state and local law. If you require
accommodation in the application process, please contact TA@ensemblehp.com.

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