Performs concurrent inpatient chart reviews for documentation improvement opportunities. Communicates with physicians to facilitated comprehensive medical record documentation to reflect clinical treatment and diagnoses, uses hospitals CDI software to identify opportunities, evaluates documentation on a day-to-day basis, gathers and analyzes information pertinent to findings and outcomes, arranges formal and informal education sessions for all providers, formulated a DRG and confers with coders to ensure appropriate DRG. This review process assures the quality of the documentation used for patient care, regulatory compliance, and reimbursement.
Completes a concurrent review of the medical record for assigned patients in the required timeframe.
Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
Associates degree (or higher) in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
2 years Acute/Inpatient experience as an RN or 5 years of inpatient coding experience
Current Registered Nurse of MN (RN) licensure or current Registered Health Information Administrator (RHIA) or Registered Health Information Tech (RHIT) credentials
Qualification Source: MN Board of Nursing or American Health Information Management Association
Bachelors degree in Nursing for candidates with nursing experience
5 years of acute care nursing or 5 years of inpatient coding experience
Certified Clinical Documentation Specialist (CCDS) for candidates with HIM experience
Qualification Source: American Health Information Management Association
Additional Requirements (must be obtained or completed within a period of time) :
Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations.
Knowledge of current coding and DRG classification systems.
Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results.
Knowledge of ICD-10-CM and DRG classification systems.
Knowledge of physician and nursing unit practices.
Excellent interpersonal, critical thinking and conflict management skills.
Computer and data analysis skills.
Excellent verbal and written communication and presentation skills.
Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions.
Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
Critical Thinking: Gathers and integrated critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions.
Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust.
Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations.
Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing.
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, ...Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.