Specialist-Clinical Documentation III RN

Specialist-Clinical Documentation III RN

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 accurate diagnosis coding and service level documentation.
• Performs quality mortality reviews to ensure documentation accuracy and maximize severity of illness and risk of mortality.
• 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; collaborates with quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC) reductions.
• Improves documentation specificity and acuity by educating physicians, clinicians, and other parties about complete and clear documentation, including capturing complications and comorbidities during the patient’s stay.
• Works independently in a hybrid work mode—both in‑facility and remotely—with multi‑facility/entity responsibility.
• Supports hospital and system initiatives and aids the HIM Department in meeting coding and billing revenue cycle requirements.
• Demonstrates knowledge of disease definitions and natural history and assesses data reflective of the patient’s clinical status to identify acuity and severity of illness.
• Establishes the working DRG assignments and collaborates with coding liaisons for accurate final DRG assignment.
• Abides by the Standards of Ethical Coding set by the American Health Information Management Association.
• Attends weekly, monthly, and/or yearly departmental meetings and educational offerings as scheduled.

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

• ICD coding experience; ICU or ED and/or Case Management experience at multi‑facilities.
• BSN (in addition to Associate’s Degree in Nursing or higher).

• Associate’s Degree in Nursing or higher.

• Knowledge of theories, principles, and concepts from RN program; strong computer skills; interpersonal, communication, and organizational skills.
• Knowledge of ICD‑10 coding; training in coding provided.

• Current state RN licensure.
• CCDS preferred but not required.