The Concurrent Documentation Specialist adheres to the processes, procedures and follow-up of program performance requirements. The Documentation Specialist addresses incomplete documentation with physicians to improve medical record Provider documentation. The primary purpose is to improve medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with Providers by clinical documentation nurse reviewers.
DUTIES AND RESPONSIBILITIES:
CDS will review new patients and transfers work list in CDR2 and review cases as assigned.
CDS will review cases from admission to discharge.
Receive assignments daily from new patient and transfers work list.
Initial reviews to be completed within 24-48 hours of admission.
Clinical signs and symptoms with available supporting documentation for query opportunity.
Incomplete information (labs, x-rays, etc.) by placing a P next to those pending and update information when available.
Identify missing information in the medical record at the time of review.
Assign the principle diagnosis and procedures, secondary diagnosis pertinent to patient condition(s), establish working DRG, and secondary diagnosis that constitutes a CC or MCC.
Concurrent reviews to be done daily. The expectation is that at least 10 new reviews will be done on a daily basis in an 8 hour shift. Re-reviews are to be done at least every 48 hours or sooner if necessary. A minimum of at least 10-15 per 8 hour shift are also expected.
Queries utilized to assist in clarification of documentation and specificity of the clinical information.
Queries are to be formulated utilizing the appropriate query templates that are available.
Queries may be verbal or written. Verbal queries must also be documented following the same process as written queries but marked as a verbal query.
Query must be supported and accompanied by relevant clinical indicators following the AHIMA guidelines for complaint queries.
Query response must be documented by the Provider in the EMR.
Query response must be documented by the CDS in CDR2 using the appropriate code.
Maintain a 25-30% query rate that is reflective of the national standards query rate per ACDIS.
Query response rates should be at least 90-95% agree rate.
Metrics will be measured for each CDI Specialist monthly and reported.
Performs other duties as necessary for accountable operations of concurrent review.
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.
Registered Nurse with a current license, BSN preferred
Minimum of 5 years of acute care nursing is desired
Knowledge of CDI Program Process is desired
Obtain CCDS certification within first year of employment or eligible for certification
As a not-for-profit community health system, Benefis is driven to provide the highest level of care. We serve nearly 230,000 residents across a 15-county region that is bigger than Connecticut, Massachusetts, New Hampshire and Vermont combined. Benefis is the largest non-governmental employer in the Great Falls area, with more than 3,000 employees.Benefis has 530 licensed beds (that includes 146 beds in long-term care, 71 in assisted living and 20 beds at Peace Hospice of Montana) and partners with over 250 area physicians.Our hospital has been recognized for its exceptional work in quality care by providing a wide range of programs and services to help you live the best life possible. We’re here to help you “Live well.”Benefis Health System came about when two Christian-based hospitals became one. Our founders believed in providing good care to all in need, and trusted that this would be accomplished. The Benefis name was derived using Latin root words: "Bene-" meaning good, and "fis-" for faith and trust. It’s these same root words that make up such terms as ‘beneficial’ and ‘confidence’.Benefis has been a trusted provider of care for more than 125 years. And our name speaks to o...ur commitment: good care one can put faith in.Benefis is consistently ranked among America’s top hospitals by the nation’s leading healthcare ratings organizations for a range of services, including cancer care, joint replacement, stroke treatment, wound care and home health.To learn more about our services, continue looking through our website at WWW.BENEFIS.ORG or call 406.455.5000.