Northwest Medical Center is a 300-bed hospital offering a full range of healthcare services including emergency services, accredited chest pain and heart failure programs, neurology and neurosurgery, outpatient imaging, a nationally accredited surgical weight loss program, total joint program, spine program and stroke center (recognized with Gold Seal designations by The Joint Commission), robotic surgery, GI lab, a free-standing women's center, inpatient rehabilitation facility, wound care center, five urgent care facilities, and three ambulatory surgery centers. NMC also has several affiliated physician practices including Northwest Allied Physicians offering primary care and a wide range of specialists, Desert Cardiology of Tucson, Heart Center of Southern Arizona and Northwest Heart & Vascular. NMC is accredited by The Joint Commission and is an equal opportunity employer: race, gender, disability and Veteran status, and VEVRAA Federal Contractor - priority referral Protected Veterans requested.
Summary: Reviews acute records of in-house patients to facilitate timely and accurate documentation and to ensure appropriate reimbursement. Provides education to physicians to assist in bridging the gap between clinical language and the requirements of documentation language for accurate, complete and compliant coding, which facilitates appropriate and accurate reimbursement. Collaborates directly with case managers, physicians, and other clinicians to ensure timely and accurate documentation. This Specialist serves as a key role to ensure a successful PHIIP (Patient Health Information Improvement Program).
1. Performs daily review of inpatient records for documentation opportunities for clarification and specificity of diagnoses and places queries on charts as necessary.
2. Assigns a working DRG and reviews documentation to identify opportunities for increased clarification and specificity of diagnoses and procedures.
3. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
4. Analyzes and trends statistical data for specified patient populations to identify opportunities for improvement.
5. Prepares educational presentations for coders, medical staff, case managers, and other departments as needed for continual documentation needs.
6. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective reviews and aggregate data analysis.
7. Works with physicians and other care givers concurrently on the units to obtain missing documentation or clarify conflicting and ambiguous documentation.
8. Monitors and evaluates the effectiveness of concurrent review outcomes as a part of the hospital's PHIIP program, trending and reporting to relevant committees throughout the year as required.
9. Efficiently demonstrate self-directed learning and participate in continuing education to meet own professional development needs and to maintain all required credentials for position.
10. Timely review of emails daily to ensure all information related to coding is reviewed and responded to in a timely manner.
Education: ADN or Diploma in Nursing Program, BSN preferred.
Experience:Licensed RN with a minimum of two years acute nursing experience or Certified Inpatient Coder with minimum of two years inpatient coding in a hospital setting, with strong clinical knowledge. Requires knowledge of ICD-9/ICD-10 coding rules and conventions, excellent verbal and written communication skills, including the ability to communicate and interact with physicians and obtain positive results.
Skills: Understands ICD-9/ICD-10 coding concepts and guidelines. Understands compliant documentation requirements. Understands regulatory compliance as it relates to documentation, coding and billing.
Licenses/Certifications: Current Arizona RN licensure.
About Northwest Medical Center & Oro Valley Hospital
Northwest Medical Center is a 300-bed community hospital with comprehensive inpatient and outpatient services, ranging from emergency to cardiac, critical care, labor & delivery and beyond. We are nationally accredited in several areas including stroke, chest pain, heart failure and joint and spine surgery. Our mission is to provide the communities we serve with high-quality cost... effective and safe health care.
For Oro Valley:
Oro Valley Hospital has been nationally recognized for its quality care including designation as a Chest Pain Center, NICHE, PEDS "Pediatric Prepared", Primary Stroke Center, STEMI Receiving Center and Trauma Level IV. That coupled with a beautiful hospital in a scenic location makes Oro Valley Hospital an exceptional place to work.