Documentation Review Nurse

Primary Position Responsibilities

• 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.
• Verify that documentation supports CPT, E&M Level, and HCPCS codes for billing and reimbursement.
• Provide constructive feedback and education to ED nursing team on documentation practices to improve compliance and clarity.
• Work closely with coding professionals to address discrepancies and clarify documentation for accurate coding.
• Ensure all documentation aligns with regulatory requirements, payor policies, and industry standards.
• Track and report on nursing documentation trends, identifying areas for improvement to enhance reimbursement and reduce denials.
• Stay up to date on changes in E&M coding guidelines, payor requirements, and clinical documentation standards.
• 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.

Qualifications

• Minimum Education: Required: Registered Nurse (RN) with an active and unencumbered license. Preferred: Bachelor of Science in Nursing (BSN) preferred.
• Minimum Years of Experience: Minimum of three (3) years clinical nursing experience. Previous nursing experience in an emergency department is required.
• Licenses, Certifications, or Registrations: RN certification is required. No additional certifications are required.
• Knowledge, Skills, and Abilities: Strong understanding of ICD-10, CPT, and HCPCS coding principles. Knowledge of Medicare reimbursement and coding structures/systems is preferred. Experience in clinical documentation improvement (CDI), coding, or utilization review is highly desirable/preferred. Excellent analytical, organizational, and communication skills are required. Proficiency in electronic health records (EHRs) and clinical documentation systems is essential. High level creativity, judgment, and initiative, tempered with flexibility to deal with rapidly changing healthcare environment and expanding technology are necessary. Self-motivation, organization, and confidence to work independently and deal with ambiguity and ask critical questions to problem solve issues as required are also needed.

Benefits

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.