Job Description

Inspire health. Serve with compassion. Be the difference.

Job Summary

Job Profile Summary
Reviews medical records to identify documentation opportunities to accurately represent the severity of illness risk of mortality length of stay intensity of service and hospital quality metrics. Reviews medical records submits provider queries and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy quality and completeness of provider documentation as well as accurate code assignment.

Job Description

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Healths purpose: Inspire with the difference.
• Conducts concurrent medical record reviews of selected patient health records to address clarity completeness consistency and accuracy of clinical documentation.
• Employs the query process as needed to provide accurate documentation reflective of patients severity of illness risk of mortality comorbid conditions length of stay principal diagnosis and present on admission (POA) status.
• Completes the reconciliation process to ensure accurate coding reflective of patients severity of illness risk of mortality comorbid conditions length of stay principal diagnosis and present on admission (POA) status.
• Develops and maintains supportive collaborative relationships with providers and health care team members to include education and follow up.
• Stay current with coding guideline changes changes in treatment modalities clinical disease indicators and compliant query policies.
• Serves as a resource for co-workers providers and other support departments (coding case management quality nutrition etc.)
• Assigns a working DRG for health care team discharge planning and CDI use.
• Performs other duties as assigned

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor manager director or executive.

Minimum Requirements

• Education - Associate degree in Nursing Health Information Management or related field of study
• Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience

In Lieu Of

• In lieu of the education and experience requirements noted above the following combination of education training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP

Required Certifications Registrations Licenses

• RHIA/RHIT/CCS/CIC/or Licensure in related field of study/ Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Knowledge Skills and Abilities

• Computer skills
• Communication skills with ability to interact with providers.
• General knowledge of IPPS ICD10 Coding MS-DRG/APR-DRG and HCPCS coding systems preferred

Work Shift

Day (United States of America)

Location

Corporate - Columbia - Taylor at Marion

Facility

Corporate

Department

Clinical Documentation Integrity

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.

Required Experience:

IC

Job Tags

Full time, Shift work

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