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Posted: Friday, February 2, 2018 3:25 AM

This is a role with combined responsibilities. As the Clinical documentation you provide clinically based concurrent and
retrospective review of inpatient medical records to evaluate the
documentation and utilization of acute care services. Includes facilitation of appropriate
physician documentation of care to accurately reflect patient severity of
illness and risk of mortality. Plays a
significant role in obtaining accurate and compliant reimbursement for acute
care services and in reporting quality of care outcomes.
As the Transition Care Coach you provide patients and caregivers with the
necessary information and support during the transition from the hospital to
home. Assists patients to successfully
manage their health care needs following a hospitalization. Follows each patient for 30 days post
hospital discharge.
Collaborates with physicians, physician extender,
nurse, case manager and Health Information Management coder to identify areas
for improved physician documentation.
Conducts initial and extended-stay concurrent
reviews on all selected admissions and documents findings on worksheets,
denoting all key information utilized in the tracking process.
Clarifies documentation in the records utilizing
assertive communication skills to guide physician, case manager, or other
healthcare professionals to make changes as appropriate to clarify
Works collaboratively with the healthcare team to
facilitate documentation within the medical record that supports patient's
severity of illness and risk of mortality in compliance with all guidelines
and requirements.
Responds to physicians queries.
Enters working DRGs into the computerized clinical
documentation system.
Utilizes monitoring tools, reports and data to
track progress.
Communicates findings with appropriate management
staff and /or providers.
Identifies the need for clinical documentation
through report analysis.
Assists in the development of physician query
response reports.
Provides education and in-service as necessary to
physicians and staff.
Maintains high productivity.
Performs efficiently regardless of fluctuation in
work volume.
Contributes to department quality improvement and
follows organizational quality customer service philosophy.
Flexible and creative on new approaches to improve
Identifies patients at high and moderate risk for
Runs daily readmission reports to identify
patients who meet criteria for the Transition Care Coach Program.
Meets with the patient at the bedside, explains
the role of the Transition Care Coach, and obtains consent. Begins the coaching relationship.
Teaches the patient/client and family/caregiver
self-care techniques as appropriate.
Provides medication, diet and other instructions. Recognizes and utilizes opportunities for
heath counseling with patients and caregivers.
Provides telephone monitoring for 30 days post
discharge from the hospital.
Completes accurate and relevant documentation.
Communicates and collaborates with physicians,
home health agencies, skilled nursing facilities, and other health care team
members as needed.
Advocates for resources on the patient's behalf
as appropriate.
Manages resources (scales, medication planners,
medication vouchers, journals, etc) appropriately while demonstrating fiscal
Attends meetings as needed and provides
presentations to educate health care team members about the role of the
Transition Care Coach.
Participates in webinars, researches journal
articles related to the reduction of readmissions and integrates current
evidence-based research into the Transition Care Coach model.
Continually evaluates the Transition Care Coach
Program and offers opportunities for improvement.
Performs other duties as assigned.
Graduate of a school of Nursing, AHIMA accredited
school, or international medical school
Currently licensed as a Registered Nurse or
Licensed Practical Nurse in the State of Missouri; or is RHIA, RHIT, or CCS
Minimum of three years clinical or inpatient
coding experience in an acute care setting required; 5 years experience strongly preferred.
Home health experience strongly preferred.
Knowledge of care
delivery documentation systems and related medical record documents.
Knowledge of
age-specific needs and the elements of disease process and related
Strong broad-based clinical knowledge and understanding of
pathology/physiology of disease process.
Excellent written and verbal communication skills.
Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering
relationships with physicians, nurse staff, hospital
management staff and
Health Information systems coding staff.
Computer literacy and familiarity with the operation of basic
office equipment.
Assertive personality traits to facilitate ongoing physician
Ability to work independently in a time sensitive
Working knowledge of Medicare reimbursement system and coding
structures/national coding guidelines.
Flexible and cooperative in fulfilling role
Demonstrates a true commitment to the success of the program
**Job:** _Non-Clinical/Administrative_
**Organization:** _Des Peres Hospital_
**Location:** _MO-St. Louis_
**Requisition ID:** _170#######_
Associated topics: coach, recruit, train, volunteer, volunteer coordinator, volunteer management, volunteer manager, volunteer orientation


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