Clinical Documentation Registered Nurse II

1 month ago

San Antonio, Texas, United States CHRISTUS Health Full time

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.


Responsibilities:
Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation
Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient
Works 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 care
Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures
Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis
Consistently meets established productivity targets for record review
Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation
Develops 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 methodologies
Assists in collection and organization of data for analysis by appropriate medical and hospital committees
Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department
Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served
Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities
Performs 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 duties
Performs other duties as assigned

Requirements:
Associate's Degree in Nursing
RN License in state of employment or compact

Work Type:
Full Time

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