Posted in Other 30+ days ago.
Type: Full Time
* Position Summary
* Under the general direction of the Physician Services Coding Director, this position is responsible for facilitating complete, accurate and consistent documentation in the medical record supporting ICD-10 diagnosis code selection to the highest level of specificity to accurately represent each patient's current health status. This includes extensive prospective medical record review and interaction with providers, care team, coders, and other staff. Active \\"at elbow\\" support and participation in team meetings and education of providers and staff is required. The position is responsible for performing quality reviews of ambulatory records to validate documentation supports diagnosis code assignment to the highest level of specificity. This also includes prospective, concurrent and retrospective reviews of ambulatory records to ensure accurate coding and spot incomplete and/or inconsistent documentation for patients that could impact the code selection and resulting risk adjustment assignment. Report results, findings and recommendations to the Physician Services Coding Director and assists with the development of process improvements to maintain data quality. This position also acts as a trainer and auditor for new and established Ambulatory CDI team members.
* Required Minimum Knowledge, Skills, and Abilities (KSAs)
* Education: BSN preferred.
* License/Certifications: Current license as a registered nurse issued by the state of Maine. CRC in one year, CCDS in 3 years.
* Experience: 5 years accrued nursing experience. Documentation auditing experience, 1 year COl CCDS preferred.
* Strong ability to apply broad guidelines to specific documentation/coding situations, independently, utilizing discretion and a significant level of analytical ability.
* Effective problem solving, analytical skills and communication skills.
* Working knowledge Risk Adjustment methodology.
* Working knowledge of Quality/HEDIS/gaps In care preferred
* Working knowledge of Microsoft Office suite
* Demonstrated ability to work independently and as part of a Care Team
MaineHealth values diversity and is an Equal Opportunity/Affirmative Action employer. Federal and state laws prohibit discrimination in employment because of race, color, national origin, religion, age, sex, sexual orientation, disability or veteran status.