Clinical Documentation Specialist- Hospice of Cincinnati

Job Responsibilities

• Collaborate with clinical managers to assure documentation corrections are made.
• Educate physicians, nursing staff, and other healthcare staff in clinical documentation guidelines related to errors in medication orders, documentation of medical orders, justification of hospice services and levels of care, synchronization and locking.
• Collaborate with the IT department to ensure that documentation from all clinical areas is captured in the Electronic Medical Record.
• Facilitate completion and submission of the Hospice Outcomes and Patient Evaluation (HOPE) to CMS as required within appropriate timeframes.
• Complete HOPE education and training with managers and nursing staff as needed.
• Facilitate the accuracy of the determination of terminal illness, terminal diagnosis, and physician certification by performing audits of new admissions/continued enrollment, using clinical documentation guidelines, LCDs, and Hospice Conditions of Participation.
• Review medical records and assemble for ADRs when requested.
• Perform audits for special needs when requested by clinical and/or quality departments.
• Establish a process to respond to RACs (Recovery Audit Contractors) from Medicare.
• Review medical records to assure accurate level of care, completeness of plan of care, and to support the billable level of care for claims submission.

Job Requirements

• Bachelor's Degree Nursing, Healthcare, Business or field (Required)
• 4 - 5 Years Experience Clinical In Nursing (Required)
• 2 - 3 years experience Clinical Hospice inpatient and/or Home care experience (Required)
• Basic keyboarding and Microsoft office Knowledge (Required)
• Knowledge of related hospice software (Required)
• Knowledge of Hospice Conditions of Participation and Joint Commission requirements for hospices (Required)
• Registered Nurse Ohio Nursing License or Multi-State Compact Nursing License Required (Required)