Works under the direction of the Director for Health Information Management/Privacy Officer. Provides clinical, technical and analytical evaluation of physician documentation and other data as necessary in order to ensure that the medical record reflects the patient’s severity of illness. Monitors, analyzes and trends the hospital’s case mix index to determine where opportunity for improvement in documentation exists and provides education to the physicians in areas identified.
- Concurrently reviews inpatient medical records to identify documentation opportunities.
- Reviews all clinical documentation to assure all pertinent conditions are documented to reflect the patient’s severity of illness and acuity of care.
- Code current diagnoses and procedures for preliminary DRG.
- Communicates documentation issues to physicians on a daily basis to resolve issues immediately.
- Educates physicians regarding the guidelines for the timeliness, completeness and appropriateness of clinical documentation.
- Educates physicians on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling, core measures.
- Identifies educational opportunities for physicians and develops educational programs to address those areas identified.
- Assesses and analyzes improvement in the quality of clinical documentation for areas of responsibility.
- Monitors, tracks and trends results of interactions and responses to physician queries.
- Collects data showing activities performed and improvements made.
- Identifies process improvement opportunities related to clinical documentation.
- Prepares administrative and clinical statistical reports on a monthly basis.
- Adheres to all federal, state and SVMH policies relating to medical records:
Assures adherence to Medicare regulations regarding medical record documentation;
Assures adherence to state and Quality Improvement Organizations (QIO) regulations regarding medical record documentation;
Assures adherence to Medical Staff Bylaws and Rules and Regulations regarding medical record documentation.
14. Adheres to all Salinas Valley Health policies, procedures and employee guidelines:
Adheres to all Salinas Valley Health policies regarding confidentiality of protected health information;
Adheres to Salinas Valley Health Code of Ethics
Adheres to all Medical Record Department policies and Departmental Guidelines.
14. Performs other duties as assigned.
Education: Bachelor’s Degree in Nursing (BSN) or a minimum of 5 years of CCS credentialing work experience required.
Licensure: Current California Registered Nurse (RN) license or current CCS credential required. CDIP or CDDS
certification required. New hires/transfer have three and a half (3.5) years from date of hire to obtain CDIP or
CCDS certification and must continually remain current.
Experience: A minimum of five (5) years’ experience in Inpatient Coding or direct patient care nursing required. Three (3) years CDI experience preferred.
The hourly rate for this position is $51.60 – $64.50. The range displayed on this job posting reflects the target for new hire salaries for this position.
