Clinical Documentation Specialist

aah; North Wilkesboro (NC); Hybride; USD 53 000 - 79 000; Plein temps

Résumé du poste

aah in United States, North Wilkesboro, NC seeks a Registered Nurse for the Clinical Documentation Improvement department. This full-time, 40-hour role is hybrid with one day onsite, dayshift, and no relocation or visa sponsorship.

You will drive accurate documentation to support MS-DRG coding, collaborate with inpatient coding, and educate providers to improve documentation quality. Requires BSN, NC RN license, and five years of bedside nursing experience; CCDS encouraged.

Qualifications

• Graduation from an accredited School of Nursing with BSN.
• Current license to practice as a Registered Nurse (RN) in the applicable state.

Responsabilités

• Facilitates appropriate clinical documentation to support the severity of illness and complexity of care.
• Reviews and resolves clinical issues in the pre-bill stage to ensure accurate DRG.
• Collaborates with case managers and nursing staff to resolve physician queries prior to discharge.
• Provides education to physicians and providers regarding documentation needs and coding guidelines.

Connaissances

Clinical documentation

RN licensure

Communication

MS-DRG coding

Education

Formation

BSN

Outils

Excel

Microsoft Word

PowerPoint

Microsoft Outlook

Description du poste

Department:

10169 Enterprise Corporate - Clinical Documentation Improvement

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

Full-time, dayshift Monday - Friday, This role will be hybrid with one day per week onsite.

No relocation and no sponsorship or transfer of visa for this position now or in the future.

Pay Range:

$38.20 - $57.30

Major Responsibilities:

• Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. Follows CDMP processes for conducting medical record reviews, assigning a working MS-DRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation appears in the medical record prior to coding and billing. Consistently meets established productivity targets for record review.
• Reviews and resolves any clinical issues arising in the pre-bill stage of medical coding to insure the most accurate DRG has been assigned for billing purposes. Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation. Prompt and professional interactions are used to effectively to resolve any deficiency.
• Collaborates with case managers, nursing staff, quality and analytics and other ancillary staff as needed regarding interactions with physicians on documentation to resolve physician queries prior to patient discharge. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages communication by promoting open dialogue.
• Provides one-on-one education to physicians, mid-level providers and other key healthcare providers regarding the need for accurate, specific and complete clinical documentation in the patient's medical record. Support ICD-10-CM/PCS training for providers by reinforcing coding conventions and guidelines.
• Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation. Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation. Participates in departmental quality assurance activities.
• Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MS-DRG assignment, documentation requirements, ICD-10-CM/PCS code assignment and coding guidelines.
• Participates in clinical documentation compliance activities including hospital acquired conditions by assuring accurate documentation resulting in the most appropriate MS-DRG assignment. Conducts pre-bill medical record reviews, assuring compliance with coding and documentation guidelines. Identifies missed opportunities related to clinical documentation and coding guidelines. Seeks additional clarification of documentation from the physician as needed in the post-discharge period in order to ensure the medical record is complete and accurate. Follows CDMP procedures for moving medical records through pre-bill process in a timely manner.
• Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.
• Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served. Knowledge of physical, motor/sensory, mental, psychosocial, safety and developmental factors in the Age-Specific Care Guidelines is reflected in reviews of patient medical records and interactions with the multidisciplinary team.

Licensure, Registration, and/or Certification Required:

• Current license to practice as a Registered Nurse (RN) in the State of applicable state. Professional certification in Clinical Documentation (CCDS) highly recommended within two years of hire.

Education Required:

• Graduation from an accredited School of Nursing with BSN.

Experience Required:

• Five years direct clinical nursing experience required.

Experience Preferred:

• Five years direct inpatient bedside experience. Especially with ED, Acute Care, Med Surg, ICU, etc.

Knowledge, Skills & Abilities Required:

• Strong oral, written, listening, and interpersonal communication skills
• Experience in developing and presenting education programs
• Competent computer skills including knowledge of Excel, Microsoft Word, PowerPoint, and Microsoft Outlook Analytical skills
• Self-motivated, self-directed and able to work independently with minimal supervision
• Able to work in a collaborative atmosphere
• Ability to accept and incorporate critical comment
• Well organized and detail oriented Capable of