Specialist-Clinical Documentation III RN

Responsibilities

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Performs Quality mortality reviews to ensure documentation accuracy and to maximize the severity of illness and risk of mortality.
• Performs reviews for risk adjustment model indicators such as CMS quality measures, present on admission, pay for performance, value based purchasing, and other national reporting initiatives.
• Works with hospital performance improvement and quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC’s) reductions.
• Improves documentation specificity, and acuity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via clarifications, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.
• Works independently in a "hybrid" work mode - working both in-facility as well as remotely and has multi-facility/entity responsibility.
• Serves as a member of the clinical team that supports specific Hospital and System initiatives and aids HIM Department in meeting their time requirement of the coding and billing revenue cycle.

Qualifications

• Minimum Required: Five (5) years of Clinical experience in an acute care facility. The experience must be pertinent and current to the specialty of the patient population.
• Preferred/Desired: ICD coding experience, ICU or ED and/or Case Management experience at multi-facilities.
• Education: Minimum Required Associate’s Degree in Nursing or higher in nursing. Preferred/Desired BSN.
• Training: Preferred/Desired.
• Special Skills: Knowledge of theories, principals, and concepts acquired through completion of RN program. Strong computer skills required. Interpersonal Communication skills, Organizational skills.
• Knowledge of ICD-10 coding however content training in coding will be provided.
• Licensure: Minimum Required Current state RN licensure or ll. Preferred/Desired CCDS.