CDI Auditor Educator

Atos Origin   •  

MI

Industry: IT Consulting/Services

  •  

5 - 7 years

Posted 271 days ago

This job is no longer available.

- Must be able to travel to various locations (75%) as required.

- The clinical documentation auditor/trainer will facilitate improvement in the overall quality, completeness, and accuracy of the medical record documentation through extensive auditinvestigation, education and data analysis.

- Comprehends, incorporates, and demonstrates Atos – Healthcare’s Mission, Vision, and Values in behaviors, practices, and decisions.

- Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.

- Communicates with and educates physicians, clinical documentation specialists and all other members of the healthcare team regarding documentation and monitors provider participation. Identifies learning opportunities for healthcare providers (i.e. CDI Boot Camp training, orientation, physician education sessions, etc.).

- Assumes the role of clinical documentation specialist providing additional cdi support to Atos’s locations as needed (i.e. vacancies, increased patient volumes, vacations, medical leave, other).

- Works to compile, analyze and evaluate quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.

- Performs CDI performance audit assessments and verifications; Evaluates processes for compliance/education effectiveness, and provides educational power point material to review high risk processes, documentation opportunities, and/or coding discrepancies.

- Performs audits investigations and reviews: Presents recommendations to management/staff regarding documentation opportunities and process effectiveness.

- Gathers and interprets clinical documentation data; Identifies documentation discrepancies, problems or issues; Determines methods to ensure compliance in accordance with clinical documentation policies and procedures.

- Identifies clinical documentation patterns and trends. Recommends areas of improvement for the pay for performance measures.

- Collaborates with coding staff to ensure complete documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolves all discrepancies in a courteous manner.

- Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience, and sound judgment. Serves as a role model by demonstrating professional practice behaviors.

- Develops and presents on-going documentation education for staff including (but not limited too) case managers, coders, physicians, residents, nursing and allied health professionals.

- Uses interpersonal skills to discuss clinical documentation issues. Works effectively with all internal personnel such as: coders, physicians, nursing, allied health professionals, and select external customers including third party payors to resolve issues.

- Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate clinical documentation requirements for both DRG reimbursement and pay for performance quality measures.

- Ensures the accuracy/completeness of clinical information used for measuring/reporting physician and hospital pay for performance diagnosis specific quality outcomes.

- Performs other duties as assigned by Leadership.

- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Atos -Healthcare Organizational Standards of Conduct, Code of Ethics

- Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required.

- Ability to educate all members of the healthcare team related to clinical documentation.

- Demonstrated ability to use a standard desktop and windows based computer system, including a basic understanding of email, internet, and computer navigation. Maintains superior excel data base skills to assure efficiencies in production of audits and data analysis. Experience with databases, spreadsheet software and presentation software preferred. Ability to use other software as required to perform the essential functions on the job.

- Comfortable operating independently in a collaborative, shared leadership environment.

 

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- Complete a clinical exam and achieve an 80% passing score.

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- Must be able to travel to various locations (75%) as required.

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- <span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">Current Registered Nurse License in the State of practice. Certified Clinical Documentation Specialist (CCDS) required. Certification will be required within 1 year and maintenance of required Continuing Education Units (CEU).

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- <span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">Experience as a Clinical Documentation Improvement auditor/trainer preferred. Inpatient coding experiencedesired.

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- <span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">Possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and at least five years of current acute hospital care experience (i.e. medical/surgical unit, intensive care).

<span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">- <span style="color: rgb(51, 51, 51); font-family: "Arial","sans-serif"; font-size: 10pt;">Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Ability to educate all members of the healthcare team related to clinical documentation

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