Clinical Document Specialist Registered Nurse Full Time

at  Regional Health

Current Employees:
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Job Category
Revenue Cycle
Department
CS Quality Safety-Risk Management
Scheduled Weekly Hours
40
Shift
Day (United States of America)
Employee Type
Regular
Job Summary
Utilizes clinical expertise to evaluate medical record chart documentation to ensure the clinical documentation reflects the level of service rendered to patients is complete and accurate. Extensive interaction with physicians and multidisciplinary team members required for facilitating modifications to the overall quality and completeness of the medical record documentation through ongoing education and monitoring. Adheres to general hospital and regulatory agency standards and promotes a cooperative work environment by utilizing communication skills, interpersonal relationships and team building.
Job Description

Essential Functions:

• Educates all internal customers on clinical documentation opportunities and coding and reimbursement issues.
• Facilitates appropriateness of clinical documentation through extensive interaction with physicians, nursing staff and coding specialists to ensure that documentation reflects the appropriate level of service rendered to all patients with a DRG based payor.
• Supports ongoing clinical documentation education for new staff, including new care managers, coders, physicians, residents, allied health professionals and nursing staff.
• Improves the overall quality and completeness of clinical documentation by performing concurrent and retrospective reviews for specific patient populations to ensure that the resources consumed, risk of mortality, and severity of illness are accurately reflected in the medical record.
• Inputs case specific information into database for each case reviewed; reviews clinical issues with Coding Specialists to ensure points of clarification have been recorded in the Medical Record.
• Reviews clinical issues and coding concerns with the coding specialists to support appropriate DRG assignment.
• Facilitates modifications to the clinical documentation, through the approved query process(es), and provides follow of non-participating providers through the appropriate channels.
• Maintains positive open communication with physicians, interdisciplinary care team members, coding specialists and department director.
• All other duties as assigned.

Additional Requirements
Required:
Education - Bachelors degree in Nursing
Certification - Registered Nurse (RN) - South Dakota Board of Nursing
Preferred:
Experience - 3+ years of Healthcare Experience
Physical Requirements:
Light work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
Make a difference . Every day.
Regional Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status

• Educates all internal customers on clinical documentation opportunities and coding and reimbursement issues.
• Facilitates appropriateness of clinical documentation through extensive interaction with physicians, nursing staff and coding specialists to ensure that documentation reflects the appropriate level of service rendered to all patients with a DRG based payor.
• Supports ongoing clinical documentation education for new staff, including new care managers, coders, physicians, residents, allied health professionals and nursing staff.
• Improves the overall quality and completeness of clinical documentation by performing concurrent and retrospective reviews for specific patient populations to ensure that the resources consumed, risk of mortality, and severity of illness are accurately reflected in the medical record.
• Inputs case specific information into database for each case reviewed; reviews clinical issues with Coding Specialists to ensure points of clarification have been recorded in the Medical Record.
• Reviews clinical issues and coding concerns with the coding specialists to support appropriate DRG assignment.
• Facilitates modifications to the clinical documentation, through the approved query process(es), and provides follow of non-participating providers through the appropriate channels.
• Maintains positive open communication with physicians, interdisciplinary care team members, coding specialists and department director.
• All other duties as assigned