Specialist-Clinical Documentation III RN

Baptist Memorial Health Care Corporation; Memphis (TN); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Baptist Memorial Health Care Corporation in Memphis is seeking a Clinical Documentation Specialist to evaluate and educate on documentation practices across complex patient populations. You will provide clinical expertise in diagnoses, procedures, and coding, while staying abreast of reimbursement changes.

The role supports documentation accuracy, DRG assignments, and participation in system initiatives, with a hybrid in-facility and remote work arrangement.

Qualifications

• Five (5) years of clinical experience in an acute care facility.
• ICD-10 coding knowledge; CCDS preferred but not required.
• Current state RN licensure is required.
• BSN preferred but not required.

Responsibilities

• Facilitates clinical documentation to support diagnosis coding and appropriate level of service.
• Performs quality mortality reviews to maximize severity of illness and accuracy.
• Reviews risk-adjustment indicators and supports national reporting initiatives.
• Educates physicians and clinicians to improve documentation specificity and acuity.
• Works in a hybrid mode with multi-facility responsibility.

Skills

RN licensure

ICD coding experience

Interpersonal communication

Strong computer skills

Organizational skills

Education

Associate’s Degree in Nursing

BSN

Job description

Overview

Job Summary

Evaluates the day to day documentation practices of the Medical Staff and healthcare team on a complex patient population, and offers education and recommendations in accordance with the Clinical Documentation Program. Provides clinical expertise in the documentation and coding of diagnoses and procedures; stays abreast of coding and reimbursement changes; promotes quality coding and serves as a resource to the coding staff. Reports to the Corporate Clinical Documentation Manager. Performs other duties as assigned.

Responsibilities

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Performs Quality mortality reviews to ensure documentation accuracy and to maximize the severity of illness and risk of mortality.
• Performs reviews for risk adjustment model indicators such as CMS quality measures, present on admission, pay for performance, value based purchasing, and other national reporting initiatives. Also works with hospital performance improvement and quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC’s) reductions.
• Improves documentation specificity, and acuity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via clarifications, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.
• Works independently in a "hybrid" work mode - working both in-facility as well as remotely and has multi-facility/entity responsibility.
• Serves as a member of the clinical team that supports specific Hospital and System initiatives and aids HIM Department in meeting their time requirement of the coding and billing revenue cycle.
• Must demonstrate knowledge of the principles of disease definitions and natural history, possess the ability to assess data reflective of the patient's clinical status, interpret the appropriate information needed to identify each patient's acuity and severity of illness.
• Establishes the working DRG assignments. When applicable, collaborates with coding liaison to determine accurate final DRG assignment.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Attends weekly, monthly, and/or yearly departmental meetings and educational offerings as scheduled

Specifications

Experience

Minimum Required

• Five (5) years of Clinical experience in an acute care facility. The experience must be pertinent and current to the specialty of the patient population.

Preferred/Desired

• ICD coding experience, ICU or ED and/or Case Management experience at multi-facilities.

Education

Minimum Required

• Associate’s Degree in Nursing or higher in nursing

Preferred/Desired

• BSN

Training

Special Skills

Minimum Required

• Knowledge of theories, principals, and concepts acquired through completion of RN program. Strong computer skills required. Interpersonal Communication skills, Organizational skills

Preferred/Desired

• Knowledge of ICD-10 coding however content training in coding will be provided.

Licensure

Minimum Required

• Current state RN licensure

Preferred/Desired

• CCDS preferred but not required