Clin Documentation Consultant Job in Oakland, California US
Clin Documentation Consultant
This position uses clinical knowledge knowledge of coded data for documentation requirements to improve overall patient quality, capture severity, acuity risk of mortality. In addition to have expertise in understanding the clinical documentation required for the completeness of the patient records using a multidisciplinary team process. Essential Functions: - Adheres to the hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships team building. - Establishes effective working relationships w/the local regional staff/teams/leadership. - Facilitates appropriate clinical documentation to support diagnosis capture to ensure the level of service rendered to all patients is recorded. - Identifies reviews primary secondary diagnosis complications to ensure diagnosis documentation capture through addendums may identify patients who need to be seen. - Identify review for POA (Present on Admission) documentation. - Reviews clinical issues w/medical coding staff w/physicians to identify those diagnoses that impact severity of illness indicators for each patient. - Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc) to ensure complete accurate diagnosis capture coding. - Collaborates in the development of programs which provide alignment w/education for internal customers to support clinical documentation guidelines. - Communicates information effectively w/medical center leaders. - Works w/Coding Review Manager to develop, implement monitor departmental policies procedures that support organizational goals, business objectives, regulatory needs requirements. - Conducts data root cause analysis, provides feedback shares findings on the analysis to leaders, local regional management medical team. - Queries medical staff for accurate clear documentation in the patients medical records. Monitor track verbal written queries produce reports as required. Qualifications: Basic Qualifications: - Minimum of 3-5 years clinical experience (i.e. inpatient, clinical documentation, discharge planning, case management). - Seasoned coders w/clinical knowledge experience w/over 10+ years may also qualify. - Graduate from an accredited school of nursing (BSN required). - Current licensure to practice as a Registered Nurse in the State of California Non-CA.Or graduate from an accredited RHIA or RHIT program (AA or BS/BA required); Or Medical Doctor license outside/inside the US. - Strong interpersonal, communication (verbal, non-verbal, listening skills). - Understand Adult Learning Theory. - Competent computer skills including word processing, spreadsheets, presentation software. - Must have strong analytical skills. - Understand coding classifications systems such as, but not limited to ICD-9 CM, Current Procedural Terminology (CPT), Healthcare Common Procedural Coding (HCPCS), MS-DRG, HCC strongly preferred. - Demonstrated ability to conduct interpret quantitative/qualitative analysis. - Proven leadership skills in project management consulting. - Must exhibit efficiency, collaboration, candor, openness, results orientation. - Demonstrate an understanding of the operations /or business of KP, health policy trends, any applicable regulations related to the responsible practice area. Preferred Qualifications: - For HIM professional a certificate is required in one of the following: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Specialist - Physician (CCS-P) 8-10 years of inpatient coding experience, including MS-DRG, APR-DRG or similar methodology.