New Hanover Regional Medical Center

NEW HANOVER REGIONAL MEDICAL CENTER

JOB DESCRIPTION AND PERFORMANCE STANDARDS

Position Clinical Documentation Improvement Second Level Reviewer

Department Clinical Documentation Improvement

Reports To CDI Manager

Approved

Approved

/

FLSA

Job Family

Origin Date 06/06/2014

Date

Date

This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance.

All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center.

JOB SUMMARY:

The Clinical Documentation Improvement Second Level Reviewer is a Professional Registered Nurse with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Manager and in collaboration with the CDI Educator. Responsibilities include secondary clinical chart reviews, resolution of DRG discrepancies, and education to clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy and improvement of capture of additional comorbid conditions to include HAC's and focused PSI diagnoses. The Clinical Documentation Improvement Second Level Reviewer will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation; collaborating with Case Managers, Outcomes Managers and Coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards.

PRIMARY JOB DUTIES:

1.  Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of prinicipal diagnosis.
2.  Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
3.  Acts as CDI representative on HAC/PSI committee, following up on identified HAC;s and PSI's. Reports these findings monthly at CDI staff meetings.
4.  Communicates findings of secondary reviews to respective Clinical Documentation staff for followup.
5.  Collaborates with CDI educator when specified educational needs are identified.
6.  Documents and tracks secondary review data. Shares this information with staff at monthly CDI team meeting.
7.  Completes Initial and follow-up medical record review using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data, and other pertinent components of the clinical record.
8.  Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately queries the provider using a concurrent query process. Follows up to insure queries are answered.
9.  Assigns the appropriate DRG, MCC's and CC’s to each record reviewed in the CDI documentation system (3MCDIS).
10.  Regularly interacts with/educates physicians to enhance understanding of the CDI program and to insure the medical record can be coded accurately in order to reflect patient severity of illness and risk of mortality.
11.  Collaborates with other clinical disciplines and members of the coding department to insure high quality clinical documentation and efficient, timely coding of the medical record.
12.  Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-CM diagnosis or DRG.
13.  Participates in performance improvement activities related to the operational processes for the Documentation Improvement Program as well as related organizational/departmental goals.
14.  Develops collaborative relationships and promotes team work with co workers and other departments.
15.  Organizes and performs work responsibilities effectively and efficiently.
16.  Maintains strict patient confidentiality, adhering to HIPPA guidelines..
17.  Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
18.  Performs other duties as assigned.

ESSENTIAL JOB SPECIFICATIONS:

1.  Education: Graduation from accredited School of nursing; BSN or Bachelors degree in health related field preferred.
2.  Licensure / Certifications: Current License to practice professional nursing in State of North Carolina. Certification in Clinical Documentation Improvement or Coding required.
3.  Experience: Minimum of 3 years experience as a Clinical Documentation Specialist required. Minimum of 5 years experience as an RN required. Must be able to demonstrate broad clinical knowledge base necessary to review a wide variety of medical records. Demonstrated positive communication skills.

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