Jackson Hospital

RN Clinical Documentation Specialist - FT, Days (44043591)
Location: Montgomery, Alabama - United States
Posted: 2/17/2018

RN Clinical Documentation Specialist - FT, Days

SCHEDULE: Full-Time, Days

The RN Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the RN Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider. Will utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation user for measuring and reporting physician and hospital outcomes. Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and Jackson Hospital query policy. Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting. Conducts educational sessions with physicians and other health care team members on documentation requirements. Reviews clinical issues and identified query response concerns with physician advisors. Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation. Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10. Understands the legal and ethical issues pertaining to confidentiality as well as liability issues for compliant coding activities. Participates in department and facility Quality and Performance initiatives. Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics. Works in conjunction with the Director of Revenue Coding CDI Documentation, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement. Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff. Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans. Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees.

Holds a current Registered Nurse License. Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred. Minimum of five years’ experience in an acute adult in-patient clinical role for RNs with demonstrated critical thinking skills , process improvement in an acute care facility preferred or equivalent experience. Coding skills with experience in ICD-10-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic, preferred. Bachelor’s degree in nursing may be substituted for two years of the required work experience. Must have strong computer skills and the ability to type on a keyboard. Prefer experience with Microsoft Office products including Excel. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner preferred. Excellent demonstrated oral, written and communication skills. Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians. Current working knowledge of one or more of the following: Medical /Surgical Nursing, Critical Care, Care and Case Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data. Experience in development of reference based continuing educational programs using Adult Learning Principles. Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor. Must be able to work independently and as a team member.

Additional Requirments / Information

Job Capacity:Employee (full-time)
Minimum Education Level:See Job Description
Visa Sponsorship: No
Related Industries:Other
No Profile Available

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