Work Shift:
Day Shift
Time Type:
Full time
Department:
CC017060 Health Information Management
Summary:
Monday to Friday, Full-time - Remote (Must reside in the state of Arkansas) Training will be onsite
Ensures overall quality and completeness of clinical documentation. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to support appropriate reimbursement and ensure that clinical severity is captured for the level of service rendered to all patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates/trains all members of the patient care team on an ongoing basis.
Additional Information:
The ideal candidate for this position will have an RN License and direct clinical experience.
Monday to Friday, Full-time - Remote (Must reside in the state of Arkansas) **Training will be onsite
Required Education:**
Associate Degree
Recommended Education:
Bachelor's Degree
Required Work Experience:
Related Field - 3 years of experience
Recommended Work Experience:
Required Certifications:
1 of the following certifications is required - , Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists, Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC), Certified Outpatient Coder (COC) - American Academy of Professional Coders (AAPC), Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC)
Recommended Certifications:
Certified Documentation Improvement Practitioner (CDIP) - American Health Information Management Association, Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA), Registered Health Information Technologist (RHIT) - American Health Information Management Association (AHIMA), Registered Nurse (RN) license - Arkansas or Compact State
Description
Facilitates appropriate clinical documentation by ensuring the overall quality and completeness by performing in-house patient medical record documentation assessments following guidelines. Reviews charts and completes clinical documentation improvement worksheet within 24 hours of admission. Identifies the most appropriate principle diagnosis and CC's to accurately reflect severity of illness in compliance with government regulations.
Confers with coding specialists to ensure appropriate working DRG and completeness of supporting documentation. Confers with physicians face to face and/or via query to clarify documentation in the record, obtain needed documentation, present opportunities and educate regarding the significance of appropriate documentation needed to support the clinical severity of the patient. Conducts follow-up reviews of clinical documentation with physicians queried to ensure points of clarification have been recorded in the patient's chart. Processes discharges by updating clinical documentation improvement worksheet to reflect any changes.
Effectively identifies DRG payor issues and improves the overall quality and completeness of clinical documentation; tracks responses and trends in compliance with the clinical documentation improvement program and reports findings. Advises co-workers on identified documentation issues and guidelines. Follows processes regarding ongoing review and follow-up of documentation goals and issues to be addressed.
Conducts ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, nursing staff and allied health professionals.
Performs other duties as assigned.
Arkansas Children's (https://www.archildrens.org/about-us) is the only hospital system in the state dedicated to caring for children, which enables us to uniquely shape the landscape of pediatric care in Arkansas.
Arkansas Children's is driven by four core values-safety, teamwork, compassion and excellence-which inform every action.
Arkansas Children's Hospital has received Magnet Status (https://www.archildrens.org/about-us/magnet-recognition) from the American Nurses Credentialing Center (ANCC), for nursing excellence and patient outcomes. And we are nationally ranked by U.S. News & World Report (https://www.archildrens.org/about-us/awards-and-recognition) for Cancer, Cardiology & Heart Surgery, Diabetes & Endocrinology, Nephrology, Neurology & Neurosurgery, Pulmonology & Lung Surgery and Urology.
For more than a century, Arkansas Children's has met the unique needs of children. But we're more than just a hospital treating sick kids-our services include two hospitals, a pediatric research institute, foundation, clinics, education and outreach, all with an unyielding commitment to making children better today and healthier tomorrow.
Arkansas Children's Little Rock campus includes a 336-bed hospital with the state's only pediatric Level 1 Trauma Center, burn center, Level 4 neonatal intensive care and pediatric intensive care, as well as a nationally-recognized transport service. And Arkansas Children's Northwest (https://www.archildrens.org/locations/arkansas-childrens-nw) provides inpatient and emergency care, clinic rooms and diagnostic services to children in that corner of the state.
"Arkansas Children's is a place of hope and comfort for children and parents. When you are at children's, you are part of an elite team united with a common goal of saving children and making their lives better." Michael - Business Operations Manager
"Arkansas Children's Hospital is a prestigious institution that cares for children." Linda - Information Systems Analyst
"We are an organization of care, love, and hope while we champion children." Angela - Parking and Fleet Coordinator
"Care, love, and hope for children!" Kathy - Administrative Assistant
"When I think of my time here at Arkansas Children's Hospital, I can honestly say that it has given me a unique perspective on the human condition, and the various roles that we all have in patient care. As a supply assistant, I have a very important job ensuring that the doctors and nurses have what they need to provide the world class medical care to the Children of Arkansas and surrounding states. Being a Champion for Children is more than a catch phrase, it is a way of life!" Nick - Supply Assistant
Arkansas Children's provides equal employment opportunity to all persons without regard to age, race, color, religion, national origin or citizenship status, disability, military status, sexual orientation, gender identity or expression, pregnancy or any other category protected by federal, state and local laws. Further, Arkansas Children's will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.
