Duties

Outpatient CDISs must be able to perform all duties of a MRT (Coder-Outpatient). CDISs serve as the liaison between health information management and clinical staff.

They facilitate improved overall quality, education, completeness, and accuracy of health record documentation. They review documentation and facilitate modifications to the health record. They identify opportunities for documentation improvement. They recommend changes and/or updates to medical center policy. They serve as a technical expert in their field. They query clinical staff to clarify documentation. They review queries through review of query reports. They perform reviews of the health record documentation. They obtain appropriate corrective action plans from clinical service directors and recommend improvements or changes. They adhere to established documentation requirements. They monitor trends in the industry and/or changes in regulations.

They are responsible for the development and implementation of active training/education programs for all clinical staff to ensure the CDIS program objectives are met. They apply applicable coding conventions and guidelines to accurately reflect medical necessity and level of service or procedure performed.

Duties include, but are not limited to:

• reviewing the overall quality and completeness of clinical documentation.
• applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure.
• reviewing clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care.
• educating providers on documentation processes in the health record, and on the need for accurate and complete documentation in the health record.
• adhering to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code.
• reviewing VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
• monitoring ever-changing regulatory and policy requirements.
• assisting staff with documentation requirements; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
• searching the patient health record to find documentation justifying code assignment. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• developing and conducting seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements.
• ensuring active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, para professional and non-professional personnel.
• facilitating improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation.
• ensuring the accuracy and completeness of clinical information. Identifying trends and/or opportunities to improve clinical documentation.
• working with the professional clinical staff and provides support and education on documentation issues. Assisting in the development of guidelines for data compatibility, consistency, and monitoring for compliance.
• providing advice and guidance in relation to documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• analyzing situations or processes and recommends improvements or changes in documentation. May assist in writing coding protocol/policies.
• using medical data incidental to a variety of patient care and treatment activities. Reviews the health record and discusses the case with the clinical staff. Performs chart reviews for specific patient populations.
• striving for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines, e.g. upcoding, unbundling, etc.

Work Schedule: Monday through Friday, 0800- 1630
Telework: Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized
Permanent Change of Station (PCS): Not authorized
Fi nancial Disclosure Report: Not required