RN, Clinical Document Spec

Job Location: 601 Elmwood Ave, Rochester, New York, United States, 14642

Full-time, 40 scheduled weekly hours

Compensation Range: $81,307.00 - $109,761.00

Responsibilities

• Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team to support the clinical severity of inpatient admission, quality documentation standards aligned with federal and state regulations, and revenue maximization.
• Recognizes gaps and facilitates modifications in clinical documentation to support accurate medical conditions for inpatient encounters.
• Uses computer software to identify documentation opportunities and conducts clinical documentation improvement efforts through query processes.
• Provides oversight of EPARC, including UM and unbilled work queues.
• Communicates with physicians and medical teams to provide guidance and clarification on principal diagnoses, complicating conditions, and diagnoses being treated for complete and accurate documentation in the medical record.
• Presents findings to key stakeholders, including leadership and peers.
• Educates peers and healthcare team members on documentation improvement, reimbursement opportunities, and overall performance.
• Demonstrates knowledge of trends in clinical diagnoses that result in payer denials.
• Ensures data validity for reporting and measuring physician and hospital outcomes through software and data analysis.
• Audits clinical documentation to confirm points of clarification have been entered in the medical record.
• Meets established productivity expectations of the CDI program.
• Maintains knowledge of hospital clinical practice guidelines to support thorough review of the medical record.
• Performs other duties as assigned.

Requirements

• Bachelor's degree in Nursing (BSN) and 5 years of inpatient clinical experience with knowledge of complex disease processes, or
• Bachelor's, Master's, or Doctorate degree in a relevant clinical discipline: Prepared Physician Assistant (PA), Nurse Practitioner (NP), Bachelor of Medicine, Bachelor of Surgery (MBBS), or Doctor of Medicine/Osteopathic Medicine (MD/DO) and 5 years inpatient clinical experience with knowledge of complex disease processes, or
• Equivalent combination of education and experience.
• Prior experience with EPARC, eRecord, HDM, and SharePoint preferred.

Qualifications

• Registered Nurse License, current in NYS upon hire, or
• Nurse Practitioner (NP) license, current in NYS upon hire, or
• Physician Assistant (PA) license, current in NYS upon hire, or
• Doctor of Medicine (MD) license, current in NYS upon hire, or
• Doctor of Osteopathic Medicine (DO) license, current in NYS upon hire.
• Clinical Documentation Specialist (CDS) certification upon hire preferred, or
• Clinical Documentation Improvement Professional (CDIP) certification upon hire preferred.