Starr Regional Medical Center is currently seeking talent to fill the position of Clinical Documentation Improvement Tech for our Health Information Department. This job is permanent, full-time.

Benefits Include:

• Competitive Pay
• Health Benefits (Medical, Dental, Vision) for full-time employees
• Competitive Paid Time Off / Extended Illness Bank package for full-time employees
• 401(k) plan with company match
• Tuition Reimbursement/Assistance for qualified applicants

Core competencies include, but are not limited to the following:

• Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses
  and procedures. Generates and obtains completed queries.
• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
• Queries physicians on specificity of procedures performed and diagnoses based on accepted coding
  guidelines, clinical expertise and LifePoint Hospitals query policy.
• Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics
  reports.
• Conducts educational sessions with physicians and other health care team members on documentation
  requirements.
• Prepares and presents educational programs to all internal constituents related to clinical documentation
  issues and coordinates same with clinical staff, physicians, compliance and coding staff.
• Makes regular reports of progress toward goals associated with clinical documentation improvement
  opportunities and operational improvement plans.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within
  the department.
• Acts as a strong advocate of the CDI program while educating physician, clinical, and other staff on the
  importance of clinically accurate documentation and the capture of data through ICD-10 coding.
• Demonstrates understanding of the importance of non-leading queries and communications with providers.
  Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation
  program.
• Reviews clinical issues and identified query response concerns with physician champion/advisors.
  Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and
  Official Guidelines for Coding and Reporting related to ICD-10.
• Works closely with case management, quality management, risk/compliance management, and medical staff
  to provide data related to key clinical indicators and operational metrics.
• Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff
  leadership and other health care disciplines to assure effective monitoring and successful completion of
  identified plans for improvement.
• Safeguards the patient's right to privacy by judiciously protecting information of the patient and medical record as per HIPAA guidelines.
• Performs other duties as assigned