Clinical Outcomes Analyst, Sr. jobs in Fort Worth, TX

The Quality Analyst is responsible for assisting with the development of process workflows, monitoring metrics/tools, developing policies and procedures, analyzing data, and supporting quality measures. This position is responsible for the implementation, support and monitoring of various initiatives and information systems including the coordination and education of quality initiatives for both inpatient and/or outpatient services.

The Clinical Appeals Nurse is part of a dynamic team that is responsible for crafting strongly defensible appeals, by leveraging critical thinking skills, for the benefit of our clients. This position leverages clinical and/or coding experience and performs medical record reviews, clinical information extraction, and support the development of appeal letters while ensuring quality and efficiency. S/he utilizes clinical data and/or coding guidelines to support defensible and accurate appeals assuring properly assigned diagnostic related grouping (DRG). The Appeals Nurse assures that the most accurate and descriptive codes from the listings of International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification and Procedure Coding System (IC10, CM and PCS) American Medical Association Current Procedural Terminology (CPT) Coding system, and Healthcare Common Procedure Coding System (HCPCS) codes supporting the patient’s treatment have been applied to a provider claim. The Appeals Nurse is a company focused self-directed, motivated individual who is able to function independently in a fast paced and continuously evolving department. S/he works collaboratively with physicians, Operations, Intake, and leadership; as well as other departments within USMD Hospital at Arlington. The individual in this role will need to be able to work independently and utilize the guidance provided. The Appeals Nurse will check the accuracy and thoroughness of their appeal prior to completing their case. 

The CDIS facilitates modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team. He or she promotes capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations. In addition, the CDIS will: 

» Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans 

» Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation, and clarify the information as warranted 

» Educate providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code sets 

» Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI 

» Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team 

» Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvement

Education & Qualifications:  Graduate of an accredited School of Nursing, BSN preferred. 

Required Licenses/Certifications:  Licensed as a Registered Nurse in the state of Texas. Certified Clinical Documentation Specialist (CCDS) preferred.  

 Work Experience:  

• Three to five years of acute care hospital experience preferred.
• Three to five years of Critical Care experience preferred.
• One to two years Quality Analyst  and CDI experience preferred.
•  

 Physical Demands & Working Conditions: The physical demands described here are representative of those that must be met by an employee to successfully to perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee is regularly required to lift up to 50 pounds and push or pull heavy objects using up to 50 pounds of force. The employee is frequently required to sit for extended periods of time. Ability to stand and/or walk for extended periods of time. Ability to use fine motor skills to operate office equipment and/or machinery. Ability to utilize full range of body motion in occasionally handling and lifting patients.  Ability to receive and comprehend instructions verbally and/or in writing.   Ability to use logical reasoning for simple and complex problem solving.  Requires Normal visual acuity and hearing.  Potential for exposure to bodily fluids.  

Special Requirements: Verbal and writing ability required to communicate effectively in informing employees of activities and policies.   Numerical ability required.   Ability to receive, comprehend, and carry out instructions; ability to work safely with equipment, supplies, and materials; ability to comply with attendance requirements; ability to comply with Human Resource policies. 

Preferred knowledge of the following: Medi-tech or other Electronic Medical Record, Quality Net, Excel and other Microsoft office products.

Essential Duties and Responsibilities:

Quality Analyst:

• Consults with administration, operations and clinical areas on operation issues including process improvement, staffing and workflow
• Conducts and interprets operational processes, workflow and/or staffing pattern studies to evaluate and provide recommendations for improvement
• Extracts and manipulates data to create reports and visual presentations
• Provides presentations as identified to various groups on project findings, analysis and/or recommendations
• Disseminates accurate data and information in a timely manner
• Run and disseminate monthly clinical PPM reports supporting all physician specialties and lines of business 
• Coordinates and facilitates process improvement initiatives from administrative and other idea sources
• Facilitate bi-directional file transfers utilizing FTP software 
• Function as data expert on various committees
• Log and track business-use data, providing reporting to senior leadership
• Utilize database query tools and reporting software to fulfill ad-hoc report requests
• Perform other duties as assigned

Clinical Appeals Nurse:

• Write clear and concise letters, handle necessary technical vocabulary, and organize difficult or complex information in an understandable and efficient manner
• Prepare clear and concise audit reports
• Serves as a liaison with third party payer and agencies regarding appeals to ensure optimal reimbursement and any other billing or payment issues and ensuring issues are resolved
• Develops recommendations to maintain efficient and effective processes
• Identifies problem accounts and escalates as appropriate
• Updates patient account record to identify actions taken on account
• Responsible for favorable resolution of third-party payment denials, adverse determinations, medical necessity denials, payment discrepancies, and contract misinterpretations
• Review whether DRG’s are assigned correctly and if all diagnosis and procedure codes are identified and documented
• Provides support to Clinical Appeals staff and serves as a resource and subject matter expert
• Conduct quality reviews and assists in feedback to the Clinical Appeals Nurse
• Monitors productivity and quality standards of the Clinical Appeals Nurses
• Assists with recruiting, interviewing, and training of employees
• Develops and maintains strong working relationships with other leaders and provides cross coverage as needed
• Other duties as assigned.

 CDI:

• Review inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation. 
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions. 
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification. 
• Conduct follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented. 
• Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with the multidisciplinary healthcare team. 
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data. 
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors. 
• Gather and analyze information pertinent to documentation findings and outcomes. 
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization. 
• Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends. 
• Identify patterns, trends, variances, and opportunities to improve documentation review processes. 
• Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician-specific data information. 
• Enhance expertise in query development, presentation, and standards (including understanding of published query guidelines and practice expectations for compliance). 

Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.