Clinical Documentation Registered Nurse II - Document Integrity

CHRISTUS Health; Beaumont (TX); On-site; USD 85,000 - 105,000; Full time

Job summary

CHRISTUS Health is seeking a Clinical Documentation RN to improve the quality and completeness of medical record documentation and to support accurate DRG assignment. The role involves extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure reimbursement reflects the services provided.

The position requires an Associate's Degree in Nursing and an active RN license in the state of employment or a compact licensure.

Qualifications

• RN licensure in state of employment or compact licensure.

Responsibilities

• Analyzes clinical status and identifies potential gaps in physician documentation.
• Communicates with attending physicians to validate observations and request more specific documentation.
• Works with HIM coding staff to ensure discharge diagnoses and co-morbidities reflect patient status.
• Maintains DRG worksheets and updates them with changes in inpatient status or procedures.
• Assists in data collection for hospital committees and designs tools to support documentation and reimbursement.

Education

Associate's Degree in Nursing

Job description

Summary:

This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

Description

Summary:

This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

Responsibilities

• Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
• Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation
• Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient
• Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care
• Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures
• Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis
• Consistently meets established productivity targets for record review
• Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation
• Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
• Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department
• Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served
• Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities
• Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties
• Performs other duties as assigned

Requirements

• Associate's Degree in Nursing
• RN License in state of employment or compact

Work Schedule

8AM - 5PM Monday-Friday

Work Type

Full Time