Clinincal Documentation Liaison Part Time Days
Req #: 17013286
Location: San Marcos, TX
Job Category: Nursing
Organization: Central Texas Medical Center
Potential Referral Bonus: $
Central Texas Medical Center
As a member of Adventist Health System, we believe that total health is achieved through a balance of physical, mental, social and spiritual well-being. With each patient’s unique circumstances in mind, our multi-disciplinary care teams provide a vast array of services, combining state-of-the-art technology with a personal commitment to creating an exceptional patient experience.
Our team members also enjoy outstanding care in the form of comprehensive health benefits, a friendly, faith-based work environment, and plenty of opportunities to learn and grow. In addition to earning the Gallup Great Workplace Award six years in a row, we have received a Mother-Friendly Worksite designation from the Texas Department of State Health Services.
Our 178-bed hospital includes a Level IV Emergency and Trauma Center, Women’s Center, Level II NICU, Sleep Improvement Center, Institute for Advanced Wound Care Healing, Rehabilitation Institute, home health and hospice care. Through our CREATION Health Institute, we also play an active role in offering free health education and community events to help support a healthy lifestyle.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
- Facilitates appropriate clinical documentation to ensure that the level of services and acuity are accurately reflected in the medical record to the extent that the physician concurs.
- Maintains knowledge of documentation requirements in accordance with AHA Coding Clinic.
- Performs admission and continued stay reviews using CDMP documentation guidelines to improve the overall quality and completeness of clinical documentation, and to ensure ordered procedures meet medical necessity guidelines..
- Assists in processing the discharges by updating the Severity/Complexity of CDMP Worksheets to reflect any changes in status, procedures/treatments, and conferring with physicians to clarify principal diagnosis.
- Educates medical and internal staff on clinical documentation guidelines.
- Conducts follow-up reviews of clinical documentation at least every 48 hours or as indicated to ensure that points of clarification with the physician have been recorded in the patient’s chart.
- Reviews clinical issues with the coding staff regarding DRG assignment.
- Ensure documentation is technically accurate on a concurrent basis that facilitates the most appropriate code assignment for PDx, PPx, Comorbid Conditions and complications.
- Confers with coding professionals concurrently to ensure appropriate DRG and completeness of supporting documentation.
- When contacted by coders, regarding concerns / disagreements about DRG or documentation issues, CDS will review the medical records and if approved, follow-up with physicians, as appropriate, in a timely manner.
- Reviews the chart with the Coding Coordinator and/or manager, if unable to reach agreement with the coding specialist.
- Participates in patient care conferences / case conferences to identify needs for clinical documentation.
- Develops and conducts ongoing CDMP education for new staff, including new clinical documentation specialist, coders, physicians, nursing and allied health professionals.
- Tracks responses to CDMP and trends / tracks compliance.
- Demonstrates clinical knowledge skills / abilities for the patient population served.
- Maintains records, documenting chart documentation compliance.
- Maintains positive open communication with physicians, inter-disciplinary care team members and department manager.
- Possesses knowledge of HCFA documentation guidelines and works with physician to achieve the appropriate documentation.
- Maintains knowledge of current guidelines through use of the Docu-Prompters and Coding Clinics
- Maintains knowledge of physician office coding with the use of appropriate Docu-Prompters.
- Demonstrates knowledgeable working expertise in the use of Microsoft Word, Power Point and Excel programs.
- Possesses knowledge of local, state and federal entitlement programs.
- Runs reports as requested by Nurse Manager, CDS’s or Administration.
- Assists in Medical Staff Presentations and updates as needed.
- Demonstrates clinical knowledge of the RAC and ADR programs.
- Performs other tasks assigned, which are within the employee’s capabilities.
What you will need:
- Bachelor's degree (B. S.) in nursing from an accredited university
- 3-5 years experience in hospital Case Management with knowledge of or certification in Case Management, coding or related fields.
- Must hold a current license as an RN in the state of Texas.