Clinical Documentation Specialist RN

Carolinas Medical Center; United States; Hybrid; USD 53,000 - 79,000; Full time

Job summary

Carolinas Medical Center is seeking a Clinical Documentation Improvement professional in the United States. The role supports the hospital's CDI program with chart reviews, physician queries, and documentation optimization to reflect accurate acuity and compliant coding.

The position is full-time with a hybrid schedule: three days onsite and two days remote, totaling 40 hours per week. RN licensure and BSN are required, along with 5 years of clinical experience in nursing or related field, and

Qualifications

• Graduate from accredited school of nursing with BSN
• Minimum 5 years of relevant clinical experience
• RN licensure required

Responsibilities

• Improve quality of clinical documentation through chart reviews
• Communicate with care team to ensure accurate documentation
• Follow up reviews to document adjudication and accuracy
• Identify principal diagnosis and complications to reflect acuity

Skills

Clinical documentation

RN experience

Communication skills

Education

BSN degree

Job description

Department:

10169 Advocate Trinity Hospital - Clinical Documentation Improvement

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

Full-time hybrid position, 3 days onsite, 2 days remote

Pay Range:

$38.20 - $57.30

Major Responsibilities:

• Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.
• 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.
• 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
• 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
• 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 in process level 25013, 5 years relevant pediatric clinical experience) Clinical documentation improvement experience preferred

Knowledge, Skills & Abilities Required:

Ability to prioritize work Excellent communication skills Good problem solving skills Critical thinking skills Basic Computer skills Effective problem-solver with good interpersonal communication skills, verbal and written Effective observat