Clinical Data Associate Jobs in Rochester, NY (NOW HIRING)

SUMMARY

The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.

STATUS: Full-time

LOCATION: Remote

DEPARTMENT: Clinical Documentation

SCHEDULE: Day shift

ATTRIBUTES

Ability to learn/develop the skills necessary to perform the CDS role
Organizational, analytical, writing and interpersonal skills
Dependable, self-directed and pleasant
Critical thinking, problem solving and deductive reasoning skills
Knowledge of Pathophysiology and Disease Process
Basic Computer skills - familiarity with Windows based software programs
Knowledge of regulatory environment
Understand and support CDS documentation strategies (upon completion of training)
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)
Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)

- For Skilled Nursing Facility Only:
a. Understand Medicare Part A guidelines
b. Understand the current FY SNF PPS Final Rule
c. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings
d. Understand the MDS Resident Assessment Instrument (RAI) Manual
e. Ability to use the CMS PDPM Calculator Tool

Minimum Qualifications:
3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.
Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.
Previous CDS experience preferred

- For Skilled Nursing Facility Only:
a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility
b. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.
OR a degree in Health Information Management (Associate's Degree with RHIT; Bachelor's Degree with RHIA)

Required Licensure/Certification:
RN, PA, NP, MBBS or MD prepared candidates.
If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire.

For Skilled Nursing Facility Only:
Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA

Rochester General Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

RESPONSIBILITIES

• Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality
  Accurate and timely record review
  Recognize opportunities for documentation improvement
  Formulate clinically credible documentation clarifications
  Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety
  Effective and appropriate communication with physicians
  Provides education to members of the patient care team regarding the CDS process.
  Timely follow up on all cases and resolution of those with clinical documentation clarifications
  Actively participate in Team Meetings
  Manage multiple priorities
  Communicates with HIM staff and resolves discrepancies
  Accurate input of data into department software

  - For Skilled Nursing Facility Only:
  a. Utilize the ICD-10-CM Official Guidelines for Coding & Reporting and their application in the long-term healthcare setting.
  b. Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.
  c. Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.

#RRHProfessional26

EDUCATION:

LICENSES / CERTIFICATIONS:

PHYSICAL REQUIREMENTS:

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee's physician or delegate will be considered for accommodations.

PAY RANGE:

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.