Documentation Integrity Specialist Home Care

Cleveland Clinic - Independence, OH (30+ days ago)4.0


Evaluates clinical records to ensure adequate collection and documentation of clinical findings, consistent with the Outcomes and Assessment Information Set (OASIS), diagnosis codes, and plan of care. Promotes compliance with home health regulations including OASIS, diagnosis coding, Medicare conditions of participation (CoP) and accreditation standards. Facilitates OASIS data integrity to ensure accurate documentation of case mix characteristics and optimal clinical and financial outcomes. Participates in ongoing analysis and reporting of outcome measures and makes recommendations for improvement at the agency and clinician level. Collaborates with managers in quality improvement initiatives and staff development. Applies effective coaching, education and training strategies to support and develop staff to their fullest potential.

Responsibilities:
Evaluates documentation and consults with staff to ensure adequate collection and documentation of clinical data that supports accurate and optimal clinical outcomes, case mix and compliance with home health regulations including CoP's and accreditation standards.
Participates in educational offerings and professional development opportunities related to OASIS, diagnosis coding and regulatory compliance to ensure continual awareness of factors related to documentation integrity.
Monitors and analyzes overall quality and case mix trends and makes recommendations for improvement to achieve department and agency goals.
Accurately assigns numeric diagnoses codes based on supportive documentation, including clinical findings and plans of care.
Collaborates with managers and agency staff to identify and implement strategies for improvement in documentation, service delivery, quality, financial, operational and compliance goals.
Employs accepted standards of practice in coaching, guiding and developing all members of the patient care team including individualized or group instruction.
Actively participates in team meetings and projects to support department and agency goals including employee engagement initiatives and ongoing assessment of effectiveness and efficiency of department operations.

Education:
If RN, BSN preferred; graduate of an accredited school of professional nursing required. If a diploma or Associates Degree of Nursing, a BSN will be required within 3years of hire date.
If PT, graduate of an accredited school of Physical Therapy. Bachelor's degree in Physical therapy required. Masters preferred.

Certifications:
Current state licensure as Registered Nurse (RN) or Current State licensure as a Physical Therapist (PT).
Home Care Coding Specialist - Diagnosis (HCS-D), Board Certified Home Health - Coding (BCHH-C) or Certified Professional Coder (CPC) within 18 months of hire.
And Certificate for OASIS specialist (COS-C) or Home Care Clinical Specialist - Oasis (HCS-O) within 18 months of hire.

Work Experience:
Four years clinical experience; two years in Home Health.
Experience with Outcomes and Assessment Information Set (OASIS): documentation, regulations and diagnosis assignment.

Physical Requirements:
None required.

Personal Protective Equipment:
Follows Standard Precautions using personal protective equipment as required for procedures.

The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.

Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities