Clinical Documentation Specialist

Nebraska Methodist Health System; Omaha (NE); On-site; USD 85,000 - 110,000; Full time

Job summary

Nebraska Methodist Health System is seeking a Nursing Documentation Specialist to support concurrent review and ensure accurate clinical reporting for inpatient care. The role emphasizes collaboration with physicians, coders, and care teams to improve documentation quality and patient acuity representation.

Qualifications include RN licensure with BSN preferred and at least five years in medical-surgical, ICU, case management or inpatient coding.

Qualifications

• Graduate of an accredited school of nursing.
• BSN preferred.
• Successful completion of annual mandatory education requirements.

Responsibilities

• Perform concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects diseases being treated.
• Assist with development of physician queries to capture correct diagnoses and severity of illness.
• Initiate communication with physicians when documentation is unclear or incomplete.
• Track responses to documentation questions to identify opportunities for physician education.
• Collaborate with coding staff to clarify documentation issues regularly.
• Maintain collaborative relationships with nurses, care coordinators and coding staff.
• Provide education and training to physicians, staff and coders in various settings.
• Partner with physicians and care teams to ensure the medical record reflects patient acuity for quality reporting.

Skills

Communication skills

Teaching skills

Critical thinking

Interprofessional collaboration

Self-starter

Education

RN license

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.

2. 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.

3. 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.

4. 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.
  • Principle diagnosis.
  • Secondary diagnosis.
• Change in Case Mix Index

5. 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

6. 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.

7. 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.

8. 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%):
  • Climbing
  • Crawling
  • Kneeling
• Occasionally Performed (1%-33%):
  • Balancing
  • Carrying
  • Distinguish colors
  • Grasping
  • Lifting
  • Pulling/Pushing
  • Standing
  • Stooping/bending
  • Twisting
  • Walking
• Frequently Performed (34%-66%):
  • Keyboarding/typing
  • Reaching
  • Repetitive Motions
  • Sitting
  • Speaking/talking
• Constantly Performed (67%-100%):
  • Hearing
  • Seeing/Visual

Job Hazards

• Not Related:
  • Chemical agents (Toxic, Corrosive, Flammable, Latex)
  • Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
  • Equipment/Machinery/Tools
  • Explosives (pressurized gas)
  • Electrical Shock/Static
  • Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc.)
  • Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
  • Mechanical moving parts/vibrations
• Rare (1-33%):
  • Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)

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 Affir­mative 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.