Documentation Clerk jobs in Madison, WI

Fort HealthCare is a patient-centered hospital and healthcare system serving individuals, businesses and families in Jefferson, Dane, and Walworth Counties, and we are seeking a Clinical Documentation Integrity Specialist to join our HIM team.

Shift:
Full time
80 hours per bi-weekly pay period
Day shift

Fort HealthCare is proud to be recognized by Modern Healthcare, a national health care publication, as one of the "Best Places to Work" as well as being named a 13-time award winner of the Milwaukee Journal/Sentinel Top Workplace award for Southeastern Wisconsin and a 3-time award winner of the USA Top Workplace award. In addition, Fort HealthCare is proud to be recognized by Chartis, a healthcare consulting firm, as one of the “Top 100 Rural & Community Hospitals” in the United States.

Our Mission Statement is our daily guide to provide the best health care possible. We promote it widely for all we serve to read, understand and to help our public hold us accountable for the promises we make.

Our Mission Statement - Improve the Health and Well-being of Our Community

Our Vision Statement provides each of us at Fort HealthCare with a goal. It is our motivation to improve constantly upon the level of care we provide, and the quality of services delivered.

Our Vision - Be the Healthiest Community in Wisconsin.

We offer competitive pay and benefits, education, and resources you need to perform your job and ample opportunities for professional growth.

The Clinical Documentation Integrity Specialist serves as a resource to the clinical team and review medical records to ensure that all relevant conditions requiring healthcare resources are accurately captured to reflect the severity of illness and benefit patient care. The CDI Specialist will collaborate extensively with FMG providers, nursing staff, patient care coordinators and coding staff to improve the quality and completeness of documentation of care provided and coding for coordination, abstraction and submission of accurate data required by CMS. This activity will help improve the patient outcomes, data quality and lead to more accurate reimbursements.

Responsibilities of this position include:

• Review the medical record on a concurrent basis to identify or obtain clarification for the appropriate diagnosis(ses) and principal procedure; and based on this review assign a preliminary DRG.
• Facilitate the overall quality and completeness of the clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated.
• Collaborate with the HIM medical coding staff to assess medical records and documents for compliance with all relevant industry regulations.
• Educate providers and clinical staff concerning accurate and effective clinical documentation in both clinic and hospital settings.
• Review the patient's medical record for serious or chronic conditions to identify HCC gaps and communicate with providers/clinic staff as appropriate.
• Collect, analyze and report HCC data to the Clinical Director for monthly Accountable Care Organization (ACO) metrics.
• Maintain and report selected HCC and CDI program metrics and key performance indicators for tracking purposes.
• Performs other duties as assigned.
• Completes department-specific orientation and annual competencies for this position.

Requirements for this position include:

• Associates degree required.
• Bachelors degree preferred.
• 5 years clinical experience in a hospital and/or clinic setting required.
• CDI experience in a hospital and/or clinic setting preferred.
• A sound clinical background with knowledge of clinical conditions, procedures, and treatment regimens; ability to analyze and interpret the clinical information in the patient's medical record; an understanding of basic documentation requirements; a working knowledge of DRG formulation, coding guidelines and guidance; highly detail oriented; exceptional analytical and critical thinking skills, excellent written and verbal communication skills as demonstrated by the ability to effectively communicate with physicians, other clinicians, and team members required.
• RN; valid WI driver license; Certified Clinical Documentation Specialist or CCDS credentials through ACDIS required.

Benefits:

• Competitive pay
• 401(k) with employer match
• Generous PTO Plan
• Daycare
• Dental insurance
• Disability insurance
• Flexible Spending
• Health Insurance
• Comprehensive Wellness Plan
• Life Insurance
• Pharmacy Discount
• Tuition Assistance
• Vision and Dental Insurance
• Employee Assistance Program
• Free Parking

Experience

• 5 year(s): 5 years clinical experience in a hospital or clinic setting.

Licenses & Certifications

• RN

Behaviors

• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization