Specialist-Clinical Documentation III RN - OB - Women's

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 the coding staff.

Reports to the Corporate Clinical Documentation Manager. Performs other duties as assigned.

• 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 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 complete and clear documentation throughout a patient’s stay. Includes capturing complications/co‑morbidities during the stay, using clarifications, face‑to‑face communications, and educational programs/tools.
• Works independently in a “hybrid” work mode – both in‑facility and remote, with multi‑facility/entity responsibility.
• Serves as a member of the clinical team supporting specific hospital and system initiatives and aids the HIM department in meeting coding and billing revenue cycle time requirements.
• Demonstrates knowledge of disease definitions and natural history; assesses data reflective of clinical status; identifies acuity and severity of illness.
• Establishes working DRG assignments and collaborates with coding liaison when applicable.
• Abides by standards of ethical coding as set by the American Health Information Management Association.
• Attends weekly, monthly, and yearly departmental meetings and educational offerings as scheduled.

• Five (5) years of clinical experience in an acute care facility, relevant to the specialty patient population.

• ICD coding experience, ICU or ED and/or case management experience at multi‑facilities.

• Associate’s Degree in Nursing or higher.

• BSN.

• None specified.

• Knowledge of theories, principles, and concepts from RN program; strong computer skills; interpersonal, communication, and organizational skills.

• Knowledge of ICD‑10 coding; content training will be provided.

• Current state RN licensure.

• CCDS preferred but not required.

Mid‑Senior level

Other

Health Care Provider

Hospitals and Health Care