Documentation Review Nurse

Req # 79982

Location: Hunterdon Healthcare System Inc., 2100 Wescott Drive, Flemington, NJ

About the role

Documentation Review Nurse Position Summary The Documentation Review Nurse will apply expertise and knowledge and review clinical documentation of Emergency Department (ED) Records to ensure accuracy, completeness, and compliance with E&M Level coding and billing standards for reimbursement purposes. This position will be reviewing the E&M Level coding and documentation of nurses. The position will support data integrity and will collaborate closely with physicians, coders, and other healthcare professionals to optimize documentation practices, improve the accuracy of coding and maximize reimbursements and minimize billing denials.

Responsibilities

• Clinical Documentation Review: Assess emergency department documentation using Emergency Department E/M and Critical Care Facility Charge Assessment tool to ensure the patient documentation accurately reflects the patient’s clinical presentation, diagnoses, and captures all treatment and services provided.
• Coding Compliance: Verify that documentation support CPT, E&M Level and HCPCS codes for billing and reimbursement.
• Education and Feedback: Provide constructive feedback and education to ED nursing team on documentation practices to improve compliance and clarity.
• Collaboration with Coders: Work closely with coding professionals to address discrepancies and clarify documentation for accurate coding.
• Regulatory Compliance: Ensure all documentation aligns with regulatory requirements, payor policies, and industry standards.
• Performance Metrics: Track and report on nursing documentation trends, identifying areas for improvement to enhance reimbursement and reduce denials.
• Continuous Learning: Stay up to date on changes in E&M coding guidelines, payor requirements, and clinical documentation standards.
• HIPAA Compliance: Maintain strict HIPAA compliance and confidentiality in reference to all information reviewed and/or discussed.
• Utilize effective critical thinking skills to resolve issues and assess and implement improved methods for efficient capture of patient services in compliance with coding and documentation regulations to ensure revenue capture and reduce denials and appeals.
• Work closely with 3rd party vendors, IT, and internal revenue cycle teams to resolve data quality issues.
• Other duties as assigned: to support the unit, department, entity and health system.

Qualifications

• Required: Registered Nurse (RN) with an active and unencumbered license
• Preferred: Bachelor of Science in Nursing (BSN)
• Preferred: Minimum of three (3) years clinical nursing experience
• Previous nursing experience in an emergency department
• Required: RN certification
• Preferred: None (for additional certifications)
• Required: Strong understanding of ICD-10, CPT and HCPCS coding principles
• Required: Knowledge