Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days

Atrium Health; Charlotte (NC); On-site; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a detail-oriented Clinical Documentation Specialist to enhance the quality of medical records. This role involves collaborating with healthcare providers to ensure accurate documentation that reflects patient severity and service rendered. You will leverage your clinical knowledge and analytical skills to educate the care team on best practices, while also utilizing licensed software tools for record reviews. Join a dynamic team dedicated to improving patient care and compliance in a supportive office environment. If you are passionate about clinical documentation and patient outcomes, this opportunity is perfect for you.

Qualifications

• Registered Nurse licensure and Bachelor's Degree required.
• 5 years of nursing experience preferred, with clinical knowledge.

Responsibilities

• Review inpatient medical records for accurate documentation.
• Educate healthcare team on documentation and coding requirements.

Skills

Clinical Documentation Improvement

Critical Thinking

Conflict Resolution

Analytical Skills

Communication Skills

Education

Bachelor's Degree

Registered Nurse North Carolina Licensure

Professional Certification

Tools

Microsoft Word

Microsoft Outlook

Microsoft Excel

Job description

Overview

Job Summary

Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.

Essential Functions

• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Physical Requirements

Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.

Education, Experience and Certifications

Registered Nurse North Carolina Licensure required. Bachelor’s Degree Required. Appropriate professional certification required within 3 years of hire date per department protocol. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred.