Clinical Documentation Specialist

Best Care; Omaha (NE); On-site; USD 75,000 - 105,000; Full time

Job summary

Nebraska Methodist Health System in Omaha is seeking a registered nurse to perform concurrent review of clinical documentation for admitted patients, ensuring accurate diagnoses and procedures are captured. You will work Mon-Fri, daytime hours at Methodist Hospital, collaborating with physicians, coders, and care teams to improve documentation quality and support quality reporting.

A BSN is preferred; an active RN license is required; five years of clinical experience in medical-surgical, ICU,

Qualifications

• Graduate of an accredited school of nursing.
• RN license current and active; multi-state/compact license acceptable.
• Five years of clinical experience in medical-surgical nursing and/or ICU, case management, or inpatient coding.
• BSN preferred; mandatory annual education requirements completed.

Responsibilities

• Performs concurrent review of clinical documentation to ensure accurate diagnoses and procedures.
• Assists with physician queries to capture severity of illness and correct ICD-10 codes.
• Initiates professional communication with physicians when documentation is unclear or incomplete.
• Tracks responses to documentation questions to identify opportunities for education.
• Collaborates with coding staff to clarify documentation issues on a regular basis.
• Provides education/training to physicians, nurses, and coders across settings.

Skills

Excellent communication

Collaboration with physicians

Teaching/education

Critical thinking

Healthcare workflow knowledge

Education

BSN preferred

Job description

Why work for Nebraska Methodist Health System?

At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary

Location: Methodist Hospital
Address: 8303 Dodge St. - Omaha, NE

Work Schedule: Mon - Fri, daytime business hours

Responsible for concurrent review of clinical documentation for all selected admissions to ensure an accurate representation of the clinical condition of the patient through complete and accurate reporting of diagnoses and procedures.

Responsibilities

Essential Functions

1. Performs concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects all disease processes being treated or affecting care while the patient is hospitalized by analyzing documentation for incompleteness, identifying ambiguous, conflicting or clinically incongruent documentation and ensure the documentation supports treatment being provided.

• 25-30 reviews performed daily.

1. Assists with the development of physician queries to ensure compliance with the query process in an effort to obtain the correct clinical diagnoses and capture of severity of illness by incorporating clinical indications and clinical knowledge in the development of the query.

• Demonstrates knowledge of an appropriate worded query that meets regulatory, legal and ethical standards.

1. Initiates assertive professional communication with physicians when documentation is unclear, incomplete or lacks the necessary completeness to assign ICD-10 codes by completing query form or face-to-face communication with the physician.

• Feedback and/or observation by supervisor of communication approach, clinical knowledge and professionalism.

1. Tracks responses to questions on documentation by trending compliance with documentation queries in an effort to identify opportunities for physician feedback and education.

• Number of MD responses to query.
• Number of changes to documentation.
• Change in Case Mix Index

1. Works with coding staff to clarify documentation issues by meeting with the coding staff on a regular basis to ensure understanding of documentation requirements.

• Feedback from coding staff

1. Maintains collaborative relationship with staff nurses, care coordinators, utilization review staff, inpatient coding staff and all hospital and health System personnel.

• Feedback from staff.
• Supervisor observation.

1. Provide education/training to physicians, physician office staff, nurses and coders in a variety of settings: One on one; Group presentations and Quick sessions during rounds.

• Presentation skills.
• Presentation materials.
• Evaluations from participants.

1. Works in partnership with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

Schedule

Mon - Fri, daytime business hours

Job Description

Job Requirements

Education

• Graduate of an accredited school of nursing required.
• Bachelor of Science in Nursing (BSN) preferred.
• Successful completion of annual mandatory education requirements.

Experience

• Five years clinical experience in medical surgical nursing and/or ICU, or case management, and/or inpatient clinical coding, and/or healthcare revenue cycle.

License/Certifications

• Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.

Skills/Knowledge/Abilities

• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.
• Develops collaborative relationships with a variety of professionals including physicians.
• Is a self starter and able to deal with resistance and complex situations.
• Ability to foster and attitude of teamwork and trust.
• Functions as an educator and enabler to physicians. Must be objective and logical.

Physical Requirements

Weight Demands

• Light Work - Exerting up to 20 pounds of force.

Physical Activity

• Not necessary for the position (0%):
• Occasionally Performed (1%-33%):
• Frequently Performed (34%-66%):
• Constantly Performed (67%-100%):

Job Hazards

• Not Related:
• Rare (1-33%):

About Methodist

Nebraska Methodist Health System is made up of four hospitals in Nebraska and southwest Iowa, more than 30 clinic locations, a nursing and allied health college, and a medical supply distributorship and central laundry facility. From the day Methodist Hospital was chartered in 1891, service to our communities has been a top priority. Financial assistance, health education, outreach to our diverse communities and populations, and other community benefit activities have always been central to our mission.

Nebraska Methodist Health System is an Assertive Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.