Clinical Documentation Registered Nurse II, Clinical Documentation Integrity
2 months ago
Summary:
This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records.
The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.
Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentationCommunicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentationMaintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patientWorks closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and careMaintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and proceduresUpdates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosisConsistently meets established productivity targets for record reviewDesigns and implements in collaboration with physician leadership specific tools to support medical record physician documentationDevelops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologiesAssists in collection and organization of data for analysis by appropriate medical and hospital committeesIdentifies strategies for sustained work process changes that facilitate complete, accurate clinical documentationDemonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the departmentAppropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member servedTakes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entitiesPerforms all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job dutiesPerforms other duties as assignedRequirements:Associate's Degree in NursingRN License in state of employment or compactWork Type:
Full TimeThis is not remote. Required to sit on-site at St. Elizabeth hospital in Beaumont, TX.
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