Registered Nurse RN - Clinical Documentation Specialist - CDIP or CCDS REQUIRED - Mon - Fri Days - Remote

About the role

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross, other payors as determined by CDI departmental goals). Ensures the accuracy and completeness of clinical information used for measuring and reporting Physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing admission / continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines.
• Facilitates modifications to clinical documentation to ensure that appropriate severity of the patient is documented and to ensure appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross and others as determined by CDI program goals).
• Conducts on-going follow-up reviews to ensure points of clarification have been recorded in the patient's medical record using department standard work to set workflow priority and scheduling.
• Works with Physicians concurrently, during the patient's stay, to educate and receive specific documentation pertinent to all requirements in question.
• Refers questionable quality, patient safety indicators, and utilization concerns to CDI Director, nursing and case management as indicated.
• Writes queries to provide professional clinical inquiry about missing documentation (clinical indicators, diagnoses, or more descriptive) for conversion to codable terms following compliant, non leading format.
• Maintains a leadership role to ensure specific and compliant documentation is achieved recognizing its use in quality measures and reporting medical center and Physician outcomes.
• Ensures documentation is meeting "medical necessity" for specific level of care and that services provided to the patient has a reasonably beneficial effect; refers cases to Utilization Review as indicated.
• Utilizes results of DRG analysis to have on-going dialogue with Physicians, nurses, coders, and case managers, to improve overall knowledge and performance.
• Participates in efforts to contain cost and/or generate revenue.
• Submits written ideas for reducing cost or adding revenue.
• Organizes and performs work effectively and efficiently by achieving daily reviews as assigned.
• Maintains and adjusts schedules to meet team performance and is willing to change workload or assignments as indicated.
• Maintains deadlines and departmental productivity standards.
• Affords assistance with special projects as needed and all other duties as assigned.
• Maintains requirements in Remote Agreement in order to retain work from home opportunity.
• Works collaboratively with CDI team members to complete daily work of the team.

Requirements

Minimum Job Qualifications:

• Licensure or other certifications: Current RN Licensure in the State of Georgia.
• Associates Degree
• Five (5) years in the practice of professional nursing.

Qualifications

Preferred Job Qualifications:

• Licensure or other certifications: CCDS or CDIP.
• Bachelor's Degree in Nursing.
• Preferred Education: Preferred Licensure or other certifications: Bachelor's Degree in Nursing. Additional education in Finance, Healthcare regulations and diagnoses-procedure coding.

Skills

Preferred Experience:

• Experience in Healthcare Utilization and Revenue Management.

Benefits

Northeast Georgia Health System offers competitive benefits including health insurance, retirement plans, and paid time off.

Pay

The salary range for this position is $XX.XX - $XXX.XX per hour, depending on experience and qualifications.

Schedule

This position works an 8-hour morning - afternoon shift.