RN Clinical Documentation Specialist
About the role
This position is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position is a member of the clinical team responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the diagnostic related group (DRG), severity of illness (SOI), risk of mortality (ROM), risk adjustment, and the complexity of patient care rendered.
Responsibilities
- Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements.
- Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities.
- Serves as the liaison between acute care coding and providers in order to capture accurate DRG, SOI, ROM, risk adjustment, reimbursement, and complexity of patient care rendered.
- Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software.
- Utilizes available resources to formulate clinically credible and compliant provider documentation clarification (queries ) aimed at improving the accuracy of the documentation process.
- Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which includes but is not limited to, accurate input of case data, correct assignment of documentation clarification types and provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting provider and facility outcomes (e.g., DRG assignment, hospital acquired conditions, patient safety indicators, quality of care, facility and system initiatives) while maintaining compliance with HIMS dept time requirements for coding and billing revenue cycle.
- Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.
Requirements
- Minimum 2-4 years of hospital acute-care or relevant clinical experience.
- Experience with acute clinical documentation programs or coding.
- Preferred: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), Certified Coding (CCS) Specialist credential, or Certified Professional Coder (CPC).
Qualifications
- Registered Nurse with active licensure in state worked, or graduate of foreign medical school with Doctor of medicine degree.
- Self-motivated, possesses moderate to strong tech skills, and able to meet daily and weekly productivity metrics.
- Works at least 75% of your shift within 7AM to 7PM AZT/MST.
- No holidays or weekends.
- Available to work in the following states: AK, AL, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & WY.
Skills
- Strong communication and interpersonal skills.
- Ability to work independently and manage multiple tasks simultaneously.
- Proficiency in clinical documentation software and coding systems.
- Knowledge of healthcare regulations and policies.
Benefits
Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.
Pay
Estimated Pay Range: $37.14 - $61.90 / hour
Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained.
EEO Statement
EEO/Disabled/Veterans
Privacy Policy
Privacy Policy