Clinical Documentation Registered Nurse II - Document Integrity

CHRISTUS Health; Beaumont (TX); On-site; USD 75,000 - 95,000; Full time

Job summary

CHRISTUS Health in Beaumont, TX is seeking a Clinical Documentation RN to improve completeness of medical record documentation and support accurate DRG assignment through collaboration with physicians and care teams. You will review inpatient records, identify documentation gaps, and guide documentation improvements with education for clinicians, while ensuring compliance and appropriate reimbursement.

This role requires an Associate's degree in nursing and an active RN license; typical schedule

Qualifications

• Associate's degree in nursing is required.
• RN license in the state of employment or a compact license is required.
• Experience with clinical documentation improvement and coding processes is preferred.

Responsibilities

• Analyze clinical status, treatment plan, and history to identify documentation gaps.
• Communicate with attending physicians to validate observations and request specific documentation.
• Maintain open communication with physicians, nursing, and other care team members.
• Collaborate with HIM coding staff to ensure discharge diagnoses reflect patient status.
• Maintain electronic DRG worksheets to identify documented diagnoses and procedures.
• Develop and implement education for physicians and staff on documentation and reimbursement.
• Ensure compliance with policies and regulatory standards.

Skills

Clinical documentation

Physician communication

Interdisciplinary collaboration

Healthcare coding liaison

Education

Associate's Degree in Nursing

RN License in state of employment or compact

Tools

DRG worksheet

HIM coding liaison

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.

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