Clinical Documentation & Integrity Specialist (Remote)

Job Description

MEMORIAL HERMANN CANNOT HIRE REMOTE WORKERS IN THE FOLLOWING STATES: Arizona, California, Connecticut, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas or Iowa

Desired Skill Sets

• Prefer an RN candidate with Clinical Documentation experience
• Must be an RN with a BSN or MSN
• Must have at least 5yrs of recent RN bedside experience in an acute hospital setting
• Must have critical care, ICU nursing experience to be considered
• Open to considering candidates with Pediatric/Neonatal experience in lieu of CDI or ICU experience

Minimum Qualifications

• Education: Bachelor of Nursing required.
• Licenses/Certifications: Current State of Texas license or temporary/compact license to practice professional nursing
• Experience / Knowledge / Skills: Five (5) years of inpatient, acute care at the bedside on a nursing unit; ICU experience preferred
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Possesses a working knowledge of many areas of adult medicine
• Able to assess, evaluate, and teach
• Proficiency in organization and planning
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
• Ability and willingness to seek out and accept change
• Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
• Knowledge of federal, state and private payer regulations preferred
• Professional, team player, able to communicate well with others
• Strong interpersonal skills and positive attitude

Principal Accountabilities

• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes.
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system.
• Gathers and analyzes information pertinent to documentation findings and outcomes.
• Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identifies patterns, trends variances and opportunities to improve documentation review and process.
• Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement.
• Aids in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information.
• Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation.
• Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness.
• Documents conference and results.
• Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities.
• Complies with HIPAA and Code of Conduct policies.
• Aids in special projects as needed.

Competencies

• Customer Service
• Job Skills
• Resource Management
• Teamwork
• Innovation