Completes audits on provider documentation. Provides feedback and education for Physicians and healthcare providers to ensure an accurate reflection of all services provided to patient.

Responsibilities:

• Perform expert level review of inpatient and observation clinical records within 48 hours of admission, as well as on a daily basis, concurrent with patient stay.
• Collaborate with inpatient and observation providers to ensure documentation accurately reflects severity of illness and acuity of care being provided as well as identify opportunities for clarification of documentation.
• Perform expert level review of outpatient clinic records and communicate with providers any opportunities for improvement of clinical documentation to support medical necessity of care rendered.
• Communicate with providers at all levels by effectively articulating queries and rationale for queries/requests for clarification. Provide follow through on all queries and requests for clarification.
• Execute provider education to promote complete and accurate clinical documentation, resulting in improved clinical documentation.
• Collaborate with coding staff to review problematic cases and ensure correct code assignment.
• Review and analyze data to identify trends, variance, and opportunities to improve documentation as well as improvement of documentation review processes. Report findings to HIM Supervisor.
• Participate on facility committees that impact documentation improvement.
• Monitors change in laws, regulations, and policies that impact clinical documentation.

Responsibilities:

• RN with 3-5 years of acute care experience OR RHIT/RHIA with 3-5 years of inpatient coding experience
• CDIP (Certified Documentation Improvement Practitioner) or CCDS (Certified Clinical Documentation Specialist) Credential preferred
• Basic knowledge of ICD-10 coding and DRG’s
• Strong interpersonal and communication skills
• Self-motivated and detail oriented
• Critical thinking and analytical skills

Schedule:

• 80hrs/2wks
• Weekdays - Flexible Schedule

Northfield Hospital & Clinics is an independent organization with over 800 employees. We are known for our positive work environment and quality patient care. We provide a full spectrum of services with our Hospital and Long Term Care Center in Northfield and primary and specialty clinics in Northfield, Lakeville, Farmington, Faribault and Lonsdale.

With us you’ll find competitive pay and benefits (when hired for 40 hours/pay period or more) including health and dental insurance, vision discount plan, life and disability insurance, PTO, tuition reimbursement, and a pension plan with a generous employer contribution.