CLINICAL DOCUMENT SPECIALIST RN -

UNM Hospital; Albuquerque (NM); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Sign-On Bonus Available

Relocation Assistance Available

Job summary

UNM Hospital in Albuquerque, NM seeks a Clinical Documentation Improvement professional to review and enhance documentation during hospitalization. You will collaborate with physicians, nurses, and coders to improve accuracy of diagnoses and procedures, supporting appropriate coding and DRG assignment.

The role emphasizes real-time queries, education of providers, and coordination across departments to ensure compliant, accurate documentation while maintaining patient confidentiality and quality

Qualifications

• RN licensed in NM or per reciprocal agreement.
• 1 year directly related experience in clinical documentation improvement.
• Bachelor's degree or higher; nursing specialization is preferred.

Responsibilities

• REVIEW - identify and record principal and secondary diagnoses and assign working MS-DRG.
• CONCURRENT REVIEW - perform initial and ongoing reviews for admissions; document findings.
• PROBLEM SOLVING - interpret clinical data and obtain documentation reflecting severity of illness.
• ABSTRACTS - track progress and report to HIM, QA, and Utilization Review.
• COMMUNICATION - obtain/clarify diagnoses with physicians; educate on documentation needs.
• COORDINATION - liaise between HIM, Utilization Review, QA, and leadership.
• PROCESS IMPROVEMENT - develop and monitor improvement plans.
• REPORTS - support distribution of physician profiling reports.
• REPORT ANALYSIS - analyze documentation to reflect severity and outcomes.
• EDUCATION - provide guidance to physicians and staff on queries and documentation.
• CONFIDENTIALITY - maintain patient confidentiality per HIPAA.
• OTHER - perform additional duties as assigned.
• COMPLIANCE - initiate clarifications via query tools to capture accurate documentation.

Skills

Clinical documentation improvement

Communication with physicians

HIPAA compliance

Education

RN licensure in NM

Bachelor's Degree

Nationally Accredited Nursing Graduate

Tools

Documentation software

MS-DRG worksheets

Job description

Receive 17% Weekday Nights, 26% Weekend Nights and 15% Weekend Day shift differentials

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: HIM Clinical Documentation

FTE: 1.00

Full Time

Shift: Days

Position Summary

Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for providers on appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed Responsibilities

• REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG
• CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
• PROBLEM SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness
• ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested
• COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
• COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Inform Coding management of potential and/or actual problems
• PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on
• REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software
• REPORT ANALYSIS - Through report analysis, review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g., physicians, committee, intra-departmental, etc.) Perform individual and group analysis of physicians and outcomes related to service line documentation issues
• EDUCATION - Provide information and education necessary to physicians and ancillary staff not responding to “queries” for appropriate follow up and consequences thereof. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coding for severity of illness and morbidity
• CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines
• OTHER - Perform other duties as assigned
• COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness and risk of mortality

Qualifications

Related Education and Experience may be substituted for one another on a year for year basis.

Education

Essential

• Program Graduate

Nonessential

• Bachelor's Degree

Education specialization

Essential

• Nationally Accredited Nursing Graduate

Nonessential

• Nursing

Experience

Essential

1 year directly related experience

Nonessential

Documentation improvement experience

Credentials

Essential

• RN in NM or as allowed by reciprocal agreement by NM

Nonessential

• Certified Coding Specialist
• Certified Doc Improvement Prac/Spec (CDIP or CDIS)

Physical Conditions

Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.

Essential

Working conditions:

• Minor Hazard - physical risks, dirt, dust, fumes, noise
• May work rotating shifts, holidays and weekends

Sign-On Bonus Available

Relocation Assistance Available