University of Miami
Clinical Documentation Specialist 2 - Concurrent Quality Reviewer - Full Time -
University of Miami, Miami, Florida, us, 33222
Clinical Documentation Specialist 2 - Concurrent Quality Reviewer - Full Time
Location: Hialeah, FL / Miami, FLTime Type: Full timePosted On: 2 Days AgoJob Requisition ID: R100079360The Concurrent Quality Reviewer of our hospital reviews documentation in the electronic medical record (EMR) and ensures accurate assignment and sequencing of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes in accordance with national coding guidelines. The primary focus of this role is to capture all encounter-specific diagnoses, procedures, and documented conditions for accurate reporting and research purposes. The goal is to achieve concurrent/real-time assignment of ICD-10 codes and DRGs by optimizing accuracy of documentation through collaboration with providers, CDIs, Coders, Quality, and other relevant multidisciplinary teams.Responsibilities:Uphold compliance by assigning and sequencing accurate ICD-10 codes to inpatient medical records as per guidelines.Determine and assign the principal diagnosis and all significant secondary ICD-10-CM diagnoses as well as Present on Admission (POA) indicator and ICD-10-PCS procedure codes.Validate the accuracy of codes assigned by the computer-assisted coding software.Analyze clinical documentation to ensure codes reported are clearly and consistently supported by the health record.Examine and ensure that the MS-DRG, APR-DRG, SOI, and ROM of each inpatient encounter is compatible and compliantly optimized.Request clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record.Abstract relevant information accurately into the computer-assisted coding application.Communicate professionally identified discrepancies and coding concerns to the appropriate department.Maintain coding quality and productivity as per departmental standards.Attend educational meetings and seminars to maintain certification and continuing education requirements.Prepare ad-hoc reports as requested by senior management.Develop, mentor, educate and provide feedback to providers and others in coding and ICD-10/DRG code assignment.Adhere to University and unit-level policies and procedures.Education:Bachelor’s degree in a related field such as Business Administration, Health Care Administration, or Health Information Management is highly preferred.Certification and Licensing:Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and/or Certified Inpatient Coder (CIC) highly desired.Experience:Minimum 5 years of coding in an inpatient hospital setting with ICD-10-CM/PCS medical coding experience.Knowledge, Skills, and Aptitudes:Attention to detail and ability to analyze, organize, and prioritize workload.Understanding of and adherence to the Health Insurance Portability and Accountability Act (HIPAA).Strong communication, organizational, and analytical skills.Proficient with Microsoft Office applications.Ability to work independently in a remote environment.The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission, and more.The University of Miami is an Equal Opportunity Employer. Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply.
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Location: Hialeah, FL / Miami, FLTime Type: Full timePosted On: 2 Days AgoJob Requisition ID: R100079360The Concurrent Quality Reviewer of our hospital reviews documentation in the electronic medical record (EMR) and ensures accurate assignment and sequencing of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes in accordance with national coding guidelines. The primary focus of this role is to capture all encounter-specific diagnoses, procedures, and documented conditions for accurate reporting and research purposes. The goal is to achieve concurrent/real-time assignment of ICD-10 codes and DRGs by optimizing accuracy of documentation through collaboration with providers, CDIs, Coders, Quality, and other relevant multidisciplinary teams.Responsibilities:Uphold compliance by assigning and sequencing accurate ICD-10 codes to inpatient medical records as per guidelines.Determine and assign the principal diagnosis and all significant secondary ICD-10-CM diagnoses as well as Present on Admission (POA) indicator and ICD-10-PCS procedure codes.Validate the accuracy of codes assigned by the computer-assisted coding software.Analyze clinical documentation to ensure codes reported are clearly and consistently supported by the health record.Examine and ensure that the MS-DRG, APR-DRG, SOI, and ROM of each inpatient encounter is compatible and compliantly optimized.Request clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record.Abstract relevant information accurately into the computer-assisted coding application.Communicate professionally identified discrepancies and coding concerns to the appropriate department.Maintain coding quality and productivity as per departmental standards.Attend educational meetings and seminars to maintain certification and continuing education requirements.Prepare ad-hoc reports as requested by senior management.Develop, mentor, educate and provide feedback to providers and others in coding and ICD-10/DRG code assignment.Adhere to University and unit-level policies and procedures.Education:Bachelor’s degree in a related field such as Business Administration, Health Care Administration, or Health Information Management is highly preferred.Certification and Licensing:Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and/or Certified Inpatient Coder (CIC) highly desired.Experience:Minimum 5 years of coding in an inpatient hospital setting with ICD-10-CM/PCS medical coding experience.Knowledge, Skills, and Aptitudes:Attention to detail and ability to analyze, organize, and prioritize workload.Understanding of and adherence to the Health Insurance Portability and Accountability Act (HIPAA).Strong communication, organizational, and analytical skills.Proficient with Microsoft Office applications.Ability to work independently in a remote environment.The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission, and more.The University of Miami is an Equal Opportunity Employer. Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply.
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