Specialist-Clinical Documentation III RN

Specialist-Clinical Documentation III RN

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Evaluates the day‑to‑day documentation practices of the medical staff and healthcare team on a complex patient population, and offers education and recommendations in accordance with the Clinical Documentation Program. Provides clinical expertise in the documentation and coding of diagnoses and procedures, stays abreast of coding and reimbursement changes, promotes quality coding, and serves as a resource to coding staff. Reports to the Corporate Clinical Documentation Manager and performs other duties as assigned.

• Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered to all patients is recorded.
• Perform quality mortality reviews to ensure documentation accuracy and maximize severity of illness and risk of mortality.
• Review for risk‑adjustment model indicators, such as CMS quality measures, present‑on‑admission, pay‑for‑performance, value‑based purchasing, and other national reporting initiatives. Work with hospital performance‑improvement and quality departments on Patient Safety Indicators and Hospital‑Acquired Condition reductions.
• Improve 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.
• Work independently in a hybrid mode—both in‑facility and remotely—and hold multi‑facility/entity responsibility.
• Serve as a member of the clinical team that supports specific hospital and system initiatives and aids the HIM department in meeting coding and billing revenue‑cycle time requirements.
• Demonstrate knowledge of disease definitions, natural history, assessment of patient clinical status, and appropriate identification of acuity and severity of illness.
• Establish working DRG assignments and collaborate with coding liaison to determine accurate final DRG assignment when applicable.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Attend weekly, monthly, and/or yearly departmental meetings and educational offerings as scheduled.

• Five (5) years of clinical experience in an acute‑care facility, current and relevant to the specialty of the patient population.
• Preferred: ICD coding experience, ICU or ED and/or case‑management experience at multi‑facilities.

• Minimum:
  Associate’s Degree in Nursing or higher.
• Preferred: BSN.

• Knowledge of nursing theories, principles, and concepts acquired through completion of an RN program.
• Strong computer skills required.
• Interpersonal, communication, and organizational skills.
• Preferred:
  Knowledge of ICD‑10 coding; content training will be provided.

• Minimum:
  Current state RN licensure.
• Preferred: CCDS (preferred but not required).