Job Summary:
Position: Clinical Documentation Medical Professional (Remote)
Location: CHRISTUS Southeast Texas St. Elizabeth Hospital, 2830 Calder Avenue, Beaumont, TX, 77702
Schedule: Monday-Friday, 8:00 AM - 5:00 PM
Contract Duration: 12 weeks
Rate: $50.13/hr
Experience: 7years
Work Hours: Guaranteed 40 hours per week
System Used: Meditech
Required Skills:
- Clinical Documentation Specialist expertise
Submission Requirements:
- Non-clinical submissions must include:
- Filled-out submission coversheet
- Resume/Work History
- Nursys if RN
- Proof of Education (Diploma, transcript, or GED; certification if required)
Required Experience:
- Minimum 3 years of experience in Health Information Management (HIM) or
- Minimum 3 years of acute hospital inpatient coding experience
Required Education/Certification:
- RHIA/RHIT/Certified Coder (Associate’s Degree in HIM required; Bachelor’s Degree in HIM highly preferred) or
- Current Texas (or compact) RN license (ADN required, BSN highly preferred) at time of submission
- CDIP or CCDS
- CCS (Preferred)
Roles & Responsibilities:
- Documentation Quality: Improve the overall quality and completeness of medical record documentation.
- DRG Assignment: Facilitate accurate Diagnosis-Related Group (DRG) assignment and ensure appropriate reimbursement.
- Interaction: Work extensively with physicians, patient caregivers, and health information management coding staff.
- Review Records: Perform concurrent and retrospective reviews of medical records using evidence-based knowledge, protocols, and criteria.
- Gap Identification: Identify gaps in physician documentation and ensure appropriate reimbursement.
- Recommendations: Provide recommendations to improve documentation quality and completeness using research, analytic data, and observations.
- Relationship Building: Establish cooperative and multidisciplinary relationships with physicians, coding staff, and other health team members.
- Resource Role: Act as a resource for the CDI department and healthcare team members regarding optimal documentation and problem resolution.
- Knowledge Demonstration: Demonstrate familiarity with MS-DRG/APR-DRG’s and the Inpatient Prospective Payment System (IPPS).
- Initial and Follow-Up Reviews: Complete initial and follow-up reviews of patient records to evaluate documentation and assign diagnoses and procedures accurately.
- Chart Review: Review a standard number of charts per day as directed.
- Analyze Information: Formulate appropriate clinical documentation clarifications and educate physicians and healthcare providers.
- Track Metrics: Track responses to clinical documentation and trends in CDI metrics.
- Continuing Education: Maintain and enhance medical, coding, and CDI knowledge through continuing education.
- Productivity Targets: Consistently meet established productivity targets for record review.
- Data Collection: Assist in collecting and organizing data for analysis by medical and hospital committees.
- Compliance: Ensure compliance with policies, procedures, and standards from state and federal agencies, the hospital, and other regulatory entities.
- Confidentiality: Protect patient confidentiality and avoid disclosing confidential information unless necessary for job duties.
Position Specific Competencies:
- Strong clinical knowledge and understanding of disease pathology and physiology
- Excellent interpersonal skills for building relationships and educating physicians, nurses, and staff
- Ability to work independently and efficiently, managing goal productivity
- Familiarity with MS-DRG and APR-DRG systems (highly preferred)
- Knowledge of medical records functions and their relation to coding
- Ability to decipher difficult handwriting in medical records
Job Type: Contract
Pay: $48.00 - $50.00 per hour
Expected hours: 40 per week
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Schedule:
Experience:
- Utilization review: 1 year (Preferred)
License/Certification:
Ability to Relocate:
- Beaumont, TX: Relocate before starting work (Required)
Work Location: On the road