[Hiring] Registered Nurse RN - Clinical Documentation Specialist @Northeast Georgia Health System

Role Description 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.

Qualifications

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

Requirements

• CCDS or CDIP preferred.
• Bachelor's Degree in Nursing preferred.
• Additional education in Finance, Healthcare regulations and diagnoses-procedure coding preferred.
• Experience in Healthcare Utilization and Revenue Management preferred.
• Demonstrates aptitude in critical care or medical-surgical nursing.
• Excellent observation skills, analytical thinking, problem-solving abilities, and excellent written and verbal communication.
• Working knowledge of DRG coding optimization strategies and clinical documentation requirements.
• Interpersonal skills including professionalism and positive approaches to the position.
• Computer skills and the ability to be self-directed.
• Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software (preferably 3M 360 Encompass).
• Leadership skills are required.
• Maintains requirements contained in Remote Agreement or forfeit the opportunity.

Essential Tasks and 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 appropriate severity of the patient is documented and appropriate reimbursement is received.
• Conducts ongoing follow-up reviews to ensure points of clarification have been recorded in the patient's medical record.
• Works with Physicians concurrently 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.
• Monitors the documentation against "core measure" quality indicators and addresses non-compliance documentation.
• Interacts regularly with Physician, nursing and case managers to ensure continuity of documentation.
• Works collaboratively with the coding staff to assign the "working" DRG to contribute for IDT Rounds.
• Processes all discharges by updating the DRG worksheet to reflect changes in patient status, procedures and/or treatments.
• Maintains a leadership role to ensure specific and compliant documentation is achieved.
• Educates various customer audiences on clinical documentation opportunities, coding, reimbursement and performance methodologies.
• Ensures documentation is meeting "medical necessity" for specific level of care.
• Demonstrates a working knowledge of the DRG system and coding guidelines.
• Utilizes results of DRG analysis to have ongoing dialogue with Physicians, nurses, coders, and case managers.
• 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.
• Meets assigned deadlines and departmental productivity standards.
• Assists with special projects as needed and all other duties as assigned.
• Maintains requirements in Remote Agreement to retain work from home opportunity.
• Works collaboratively with CDI team members to complete daily work of the team.

Physical Demands

• Weight Lifted: Up to 30 lbs, Occasionally 0-30% of time.
• Weight Carried: Up to 30 lbs, Occasionally 0-30% of time.
• Vision: Moderate, Frequently 31-65% of time.
• Kneeling/Stooping/Bending: Occasionally 0-30%.
• Standing/Walking: Frequently 31-65%.
• Pushing/Pulling: Occasionally 0-30%.
• Intensity of Work: Frequently 31-65%.
• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving.