Clinical Documentation Specialist

About the role

Nebraska Methodist Health System focuses on providing exceptional care to the communities they serve and the people they employ. This is known as The Meaning of Care – a culture that sets them apart. It involves helping families grow by making each delivery special, conveying difficult diagnoses with a compassionate touch, going above and beyond for a patient's needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. They offer competitive pay, excellent benefits, and a great work environment where all employees are valued.

Responsibilities

• Performs concurrent review of clinical documentation for all selected admissions to ensure an accurate representation of the clinical condition of the patient through complete and accurate reporting of diagnoses and procedures.
• Assists with the development of physician queries to ensure compliance with the query process in an effort to obtain the correct clinical diagnoses and capture of severity of illness by incorporating clinical indications and clinical knowledge in the development of the query.
• Initiates assertive professional communication with physicians when documentation is unclear, incomplete or lacks the necessary completeness to assign ICD-10 codes by completing query form or face-to-face communication with the physician.
• Tracks responses to questions on documentation by trending compliance with documentation queries in an effort to identify opportunities for physician feedback and education.
• Works with coding staff to clarify documentation issues by meeting with the coding staff on a regular basis to ensure understanding of documentation requirements.
• Maintains collaborative relationship with staff nurses, care coordinators, utilization review staff, inpatient coding staff and all hospital and health System personnel.
• Provides education/training to physicians, physician office staff, nurses and coders in a variety of settings: One on one; Group presentations and Quick sessions during rounds.
• Works in partnership with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

Requirements

• Graduate of an accredited school of nursing required.
• Bachelor of Science in Nursing (BSN) preferred.
• Successful completion of annual mandatory education requirements.
• Five years clinical experience in medical surgical nursing and/or ICU, or case management, and/or inpatient clinical coding, and/or healthcare revenue cycle.
• Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.

Skills/Knowledge/Abilities

• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.
• Develops collaborative relationships with a variety of professionals including physicians.
• A self starter and able to deal with resistance and complex situations.
• Ability to foster and attitude of teamwork and trust.
• Functions as an educator and enabler to physicians.
• Must be objective and logical.

Physical Requirements

• Weight Demands: Light Work - Exerting up to 20 pounds of force.
• Physical Activity: Not necessary for the position (0%).
• Climbing: Occasionally Performed (1%-33%).
• Crawling: Not Performed.
• Kneeling: Frequently Performed (34%-66%).
• Carrying: Not Performed.
• Crouching: Not Performed.
• Distinguish colors: Frequently Performed (34%-66%).
• Grasping: Frequently Performed (34%-66%).
• Lifting: Frequently Performed (34%-66%).
• Pulling/Pushing: Frequently Performed (34%-66%).
• Standing: Frequently Performed (34%-66%).
• Stooping/bending: Frequently Performed (34%-66%).
• Twisting: Not Performed.
• Walking: Frequently Performed (34%-66%).
• Keyboarding/typing: Constantly Performed (67%-100%).
• Reaching: Frequently Performed (34%-66%).
• Repetitive Motions: Frequently Performed (34%-66%).
• Sitting: Frequently Performed (34%-66%).
• Speaking/talking: Constantly Performed (67%-100%).

About Nebraska Methodist Health System

Nebraska Methodist Health System is made up of four hospitals in Nebraska and southwest Iowa, more than 30 clinic locations, a nursing and allied health college, and a medical supply distributorship and central laundry facility. From the day Methodist Hospital was chartered in 1891, service to our communities has been a top priority. Financial assistance, health education, outreach to our diverse communities and populations, and other community benefit activities have always been central to our mission. Nebraska Methodist Health System is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.