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Clinical Documentation Coord/mmc/ft/8a-5p

McAllen Medical Center

This is a Contract position in Mcallen, TX posted May 31, 2019.

JOB SPECIFIC DUTIES (minimum 5 / maximum 12) 40% weight in overall rating Provides concurrent review of the clinical documentation in the medical record and queries the medical staff as necessary via written/verbal communication to obtain accurate and complete physician documentation to support severity of illness and risk of mortality in the DRG Assurance program.

Rating: Comments: Collaborates with physician, physician extender, nurse, case managers/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnosis and procedures, to assign working DRGs for at least 85% of the identified populations.?

Able to utilize inpatient admission criteria to assign only diagnosis that meet acute care criteria.


Comments: 3.Demonstrate an understanding of the importance of and performs a thorough chart review to capture all secondary diagnoses and comorbidities/complications appropriately.


Comments: 4.?

Completes the DRG worksheet and reviews documentation in the medical record according to???????????????


Updates information in Documentation Improvement tracking system in a timely manner.


Comments: 5.Demonstrates creativity and enthusiasm while pursuing the goals of the department and STHS.


Comments: 6.Maintains the ability to be flexible and prioritizes daily responsibilities appropriately.


Comments: 7.Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data.?

Shares findings with identified staff at DRG Assurance meetings.?

Able to identify areas of focus through report analysis.?

Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.


Comments: 8.?Assists in the development of APR/DRG query response physician reports.

Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.


Comments: 9.?Provides information and in-services as necessary to physicians and ancillary staff.


Comments: 10.?Performs other tasks as assigned.


Comments: :: Job Requirements QUALIFICATIONS: Excellent written and verbal communication skills required.

Excellent critical thinking skills required and must be detail oriented.

Knowledge of age-specific needs and elements of disease process and related procedures required.Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.

Ability to work independently in a time-oriented environment is essential.

Working knowledge of Medicare reimbursement system and coding structures preferred, by not required.

Computer literacy essential.

Must demonstrate commitment and adherence to STHS?s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer.

EDUCATION / LICENSURE: Associate or Bachelor?s Degree in Nursing or Health Informtion Management; Advanced degree such as medical doctor, nurse practitioner, or physician assistant acceptable.

Minimum of 3-5 years clinical experience in an acute care setting; Critical Care, Medical/Surgical or Emergency Department nursing preferred.

Must be able to travel between facilities as needed.