Specialist-Clinical Documentation III RN

Baptist Memorial Health Care; Meridian (MS); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Baptist Memorial Health Care in Meridian, MS seeks a Clinical Documentation Specialist to evaluate and educate on documentation practices, ensuring accurate diagnoses, procedures, and coding. The role reports to the Corporate Clinical Documentation Manager and supports hospital and system initiatives.

Requirements include RN licensure, 5 years acute care experience, strong ICD-10 coding knowledge (preferred), and excellent computer and communication skills.

Qualifications

• Five (5) years of clinical experience in an acute care facility.
• Strong computer, interpersonal, and organizational skills.
• Current state RN licensure.
• Knowledge of ICD-10 coding preferred; content training will be provided.
• Hybrid work model across multiple facilities and entities.

Responsibilities

• Facilitates appropriate clinical documentation to support accurate diagnosis coding and appropriate level of service.
• Performs quality mortality reviews to ensure documentation accuracy and maximize severity of illness.
• Performs reviews for risk adjustment indicators and supports system initiatives with HIM/Quality teams.
• Educates physicians, clinicians, and other involved parties on the necessity of complete and clear documentation throughout a patient’s stay.
• Works in a hybrid in-facility and remote setting with multi-facility responsibilities.
• Aids HIM Department in meeting coding and billing revenue cycle timelines and goals.
• Keeps abreast of disease definitions and associated clinical status data and DRG assignments.
• Attends departmental meetings and educational offerings as scheduled.

Skills

RN background

Clinical documentation

Interpersonal skills

Organizational skills

Computer skills

Education

Associate's Degree in Nursing

BSN

Job description

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.

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

Preferred/Desired

Minimum Required

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