The Lead Concurrent Documentation Specialist supports and provides oversight for programs including mentoring and leadership to Concurrent Review team on Program process, procedures, approach and monitors. Evaluates follow-up of program performance and use for modifying approach and or developing focus areas. The Documentation Specialist Lead addresses incomplete documentation with Providers to improve medical record Provider documentation. The primary purpose is to oversee the Clinical Documentation Specialists and improve medical record Provider documentation by performing concurrent medical record reviews and addressing incomplete documentation with Providers by clinical documentation nurse reviewers.
DUTIES AND RESPONSIBILITIES:
Assesses and monitors the performance of Clinical Documentation Specialists (CDS).
Adjusts the workloads of the CDS to insure daily targets are being achieved.
Advises and serves as a resource to CDS in achieving concurrent documentation objectives.
Assists the CDS to probe thoroughly into the clinical documentation to identify potential gaps in clinical documentation (missing, unclear or conflicting documentation and query opportunities).
Facilitates teaching of the CDS in critical thinking, translation, and interpretation skills where Provider clinical language and/or the coding language intersect.
Resolves discrepancies between the CDS and Coders in cooperation with the Lead Coder/CDS Liaison.
Performs as assigned second level reviews with appropriate follow-up on results.
Performs quality review activities ie. Reviewing 5 cases per CDS every other week and reviewing Coder feedback on CDS worksheets.
Measures CDS productivity and effectiveness by evaluating other aspects of CDI process including Provider participation.
Collects and shares ongoing metrics with staff.
Leads, coordinates and maintains an agenda for regularly scheduled Program meetings between CDS and Coders.
Confers with Physician Advisor on difficult and complex cases, obtains advice on issues related to Provider compliance with respect to queries.
Refers problem cases to Physician Advisor for review.
Participates in meetings with Providers to relay information concerning Program coding rule changes, focus areas for outcome and process changes including discussions of query activity and purpose.
Acts as resource for policies, procedures, related to concurrent review.
Uses CDR2 to monitor and interpret all aspects of CDI Program and maintains integrity of data collection, ensures accurate data entry, demonstrates competence in navigating in CDR2, and utilizes CDR2 as a resource in ensuring accurate documentation.
Fills in for CDS when staff are absent, assists CDS during spikes in case load, goes to units and interfaces with Providers to assist with pending queries, promotes CDI program, interfaces with nursing to solicit understanding and assistance in documentation specificity for Providers.
Has current knowledge of healthcare regulations, clinical knowledge of pathophysiology, skills in clinical terminology, coding and classification systems.
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.
BSN required, MSN Preferred
CCDs certification required
ICD 10 training required
Registered Nurse with a current license
Minimum of 5 years of acute care nursing is desired
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 ‘be...neficial’ and ‘confidence'. Benefis has been a trusted provider of care for more than 125 years. And our name speaks to our 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.