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MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or equivalent.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Five (5) years of Clinical experience in a hospital setting with a working knowledge of Epic.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Reviews outstanding core measure items and related documentation.

2. Reviews Certified Data Management Professional (CDMP) and coding queries.

3. Addresses inappropriate and/or inadequate documentation practices with clinician.

4. Offers assistance with documentation optimization; facilitates use of available system resources.  Records process activities to reflect any changes in status, procedures/treatments, query activity, and physician activities.

5. Actively participates in multidisciplinary rounds.

6. Responsible for the education of staff and physicians in the CDI Program process.

7. Identifies educational needs and provides training.  Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies, system navigation.

8. Participates in the monitoring of quality indicators, as requested.

9. Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through interaction with physicians, nursing staff, medical record coders, and IT.

10. Coordinates with HIM to bring to the physician’s attention any potential change in principle diagnosis and/or diagnosis that reflect complication, comorbidity, and severity that should be included in the patient’s medical record.

11. Reviews HIM and Quality audits for documentation/education needs.

12. Remains current on workflow changes in Epic.

13. Coordinates with IT build teams for needs of clinicians.

14. Works with providers to create consistency in documentation practices.

15. Participates in training to remain proficient in Epic modules and workflows.

16. Collaborates with the appropriate departments or committees for resolution of identified concerns.  Provides feedback to physicians, departments, and committees as appropriate.

17. Supports documentation requirements for JCAHO and state requirements.  Reduces risk that may exist when clinical documentation is incomplete or unclear.

18. Prepares reports on a weekly, quarterly, and/or annual basis as required/requested by manager.

19. Ensures compliance with all federal and state regulations and facilitates improvement in documentation through concurrent interaction with physicians, medical record coders, and other healthcare team members.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to use computer keyboard, monitor, and mouse. 

2. Ability to communicate verbally, in writing, and electronically with healthcare personnel.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to work under stress.

2. May be exposed to communicable diseases.

SKILLS AND ABILITIES:

1. Functional knowledge of Electronic Medical Record (EMR).

2. Critical thinking skills.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Compensation Range:

Position is eligible for shift differentials based on shift worked and eligible for overtime pay hours over 40 hours per week

Company:

Cost Center:

Address:

Benefit eligible employees classified as at least 0.5 eligible for: Medical, Dental, Vision, Disability Coverage, Tuition Program, Retirement, Paid Time Off, Wellness Program

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.