Clinical Documentation Specialist (Pediatric Exp Required) 1.0 days

Carolinas Medical Center; United States; Hybrid; USD 53.000 - 79.000; Vollzeit

Zusammenfassung

Carolinas Medical Center is seeking a Nurse Documentation Specialist with inpatient pediatrics experience. The role requires a BSN and at least five years of nursing practice, including NICU/PICU or pediatric medical/surgical settings.

The position is on-site with a hybrid arrangement and involves direct collaboration with physicians and other health professionals. The role emphasizes accurate documentation, coding support, and performance improvement.

Qualifikationen

• Minimum 5 years nursing experience with BSN.
• Inpatient hospital nursing experience in pediatrics medical/surgical or NICU/PICU.
• Strong clinical skills and ability to work with physicians and allied health staff.

Aufgaben

• Evaluate documentation daily in compliance with hospital policies.
• Provide clinical evaluation of medical records including labs, diagnoses and treatment plans.
• Clarify missing or conflicting documentation with physicians to improve accuracy and coding.

Kenntnisse

Nursing experience

RN license

Clinical documentation

DRG coding

Ausbildung

BSN degree

Tools

Coding systems

Medical records software

Jobbeschreibung

Department:

11207 ACH Enterprise - Compliance Document Management Program

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

Candidate must have inpatient hospital nursing experience in pediatrics medical / surgical or NICU or PICU patient populations. Minimum 5 years nursing experience with BSN. Will not accept applicants with only obstetrics or psych nursing background. Strong clinical skills are necessary to be able to be successful in this role. Position will require in-person work with physicians and other allied health professionals. On-site work requirement. This is a hybrid position.

Pay Range:

$38.20 - $57.30

Major Responsibilities:

• 1)Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures
• 2)Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• 3)Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• 4)Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• 5)Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient's chart.
• 6)Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• 7)Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• 8)Gather and analyze information pertinent to documentation findings and outcomes
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.
• 1)Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.
• 2)Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation
• 3)Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• 4)Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• 5)Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff
• 6)Maintains knowledge of current standards of care via literature review and participation in educational offerings
• 7)Research literature to identify new methods development and overall documentation enhancement
• 8)Complete required contact hours based on FTE status, within time frame
• Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.
• 5)Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.
• 1)Completes documentation on reviewed cases in the database.
• 2)Completes the DRG and query indicators for each reviewed case, as appropriate.
• 3)Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.
• 4)Identify patterns, trends variances and opportunities to improve documentation review and process
• Demonstrate positive and effective interpersonal relations dealing with all members of the team (ie co-workers, physicians, leadership, etc.).
• 1)Maintains a positive attitude about assignments and team members
• 2)Promotes professional/personal growth of co-workers by sharing knowledge and resources.
• 3)Manages stress and personal feelings without a negative impact on the team
• 4)Communicates in a positive and productive manner.
• 5)Demonstrates flexibility with changing workload/assignments.

Licensure:

Nurse, Registered (RN)

Education/Experience Required:

Graduate from an accredited school of nursing BSN 5 years relevant clinical experience (For associates