Provides clinically based concurrent and retrospective review of inpatient, outpatient and Diversified Clinic medical records to evaluate the utilization and documentation of patient care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
ESSENTIAL JOB FUNCTIONS:
1. Conducts initial and extended-stay concurrent reviews on all selected admissions, and documents findings within CDIS (electronic review system), denoting all key information (including working DRG and queries) utilized in the tracking process.
2. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria. In the advent that diagnosis does not meet admission criteria, communicates with Case Management Department to determine the appropriate patient status.
3. Collaborates with physician, physician extender, nurse, case manager/utilization review and HIM coder to identify principal diagnosis options, secondary diagnoses including complications and comorbidities, and procedures, to assign working DRGs for at least 80%-85% of the identified populations.
4. Identifies need to clarify documentation in medical records, and utilizes strong communication skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professional, utilizing appropriate tools to capture needed documentation.
5. Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of the CDIS tracking reports, monitoring reports and data. Able to identify areas of focus through report analysis. Serves as a resource to physicians and Administration regarding issues related to the appropriateness of inpatient DRG assignment.
6. Assists in the development of APR/DRG/query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
7. Provides information and in-services as necessary to physicians and Ancillary Department staff.
8. Role models the principles of a Just Culture.
9. Perform other duties as assigned. Must be HIPAA compliant.
This description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum of five (5) years of clinical experience in an acute care setting; critical care, medical/surgical or Emergency Department nursing preferred.
Ability to obtain and maintain a State of Colorado Registered Nurse license.
CDIP and CCS Certifications preferred.
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
Must have working knowledge of the English language, including reading, writing, and speaking English.
Associates or Bachelor's Degree in Nursing required.
Internal Number: 7718
About Vail Health
Vail Health, formerly Vail Valley Medical Center, is a nonprofit community health care system serving patients and guests from around the world. Locally operated and governed by a volunteer board of directors, Vail Health includes a 56-bed hospital, accredited by the Joint Commission. Our 24/7 emergency department in Vail is a Level III Trauma Center with a nearby helipad for necessary medical transports. Vail Health provides a wide array of services and access points including Beaver Creek Medical Center, urgent care clinics in Avon and Gypsum, our Edwards medical campus, Eagle Healthcare Center and a multispecialty clinic in Frisco. Howard Head Sports Medicine offers physical therapy services at 10 locations and works closely with our internationally renowned orthopaedic partners at The Steadman Clinic and Vail-Summit Orthopaedics. In addition, Vail Health's Shaw Cancer Center and Sonnenalp Breast Center are the region’s only fully accredited cancer treatment center and comprehensive breast center. The Vail Clinic, which was founded in 1965, officially became “Vail Valley Medical Center” in 1980, its first year as a full-service hospital. At that time, we had one primary locatio...n and 25 physicians. Today, Vail Health has locations in nine towns, nearly 1,000 employees, 260 physician partners and 85 volunteers. Vail Health is an equal-opportunity employer. The hospital is handicap accessible and adheres to the Americans with Disabilities Act. Smoking is prohibited in our facilities. This includes e-cigarettes.