Clinical Documentation Specialist Rn

5 days ago

Edison, United States Hackensack Meridian Health Full time

Overview:
The **Clinical Documentation Specialist RN** facilitates improvement in the overall quality, completeness and accuracy of medical record documentation for assigned hospital/s of Hackensack Meridian Health (HMH). Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of the patient care team on documentation guidelines, on an on-going basis. Reviews and screens ED inpatient admissions and observations as specified by the facility's Utilization Management/Review Committee for documentation completeness and compliance with patient status. Facilitates accurate documentation for severity of illness and medical necessity. Interacts with physicians, case managers, and nursing staff and provides guidance and recommendations for admission or observation disposition. Assesses patients for present-on-admission (POA) conditions to ensure accurate documentation, regarding hospital acquired conditions (HAC). Communicates the transfer of appropriate concurrent information to the inpatient Case Managers and the Clinical Documentation Specialists (CDS), assigned to the unit.

Qualifications:
**Education, Knowledge, Skills and Abilities Required**:

- Graduation from a bachelor's level program of Nursing (or in select cases, may allow to obtain within 2 years of hire).
- Minimum of 5 or more years of recent clinical experience, preferably in Medical/Surgical Critical Care, Intensive Care or Emergency Room Care.
- Ability to interact well with physicians and other members of allied health care teams, including HIM coders.
- Must possess excellent communication, organizational, analytical, writing and interpersonal skills.
- Dependable, self-directed and pleasant.
- Critical thinking, problem solving and deductive reasoning skills.
- Recent hospital experience.
- Knowledge of Pathophysiology and Disease Process.
- Knowledge of Medicare Part A.
- Familiar with Medicare Part B.
- Knowledge of the regulatory environment.
- Understand and support CDMP documentation strategies.
- Knowledge of POA/HAC and core measures.
- Knowledge of Observation and Inpatient medical necessity.
- Knowledge of regulatory requirements for appropriateness of admissions.

**Education, Knowledge, Skills and Abilities Preferred**:

- Advanced Practice Degree.
- ICU, CCU and/or strong Medical/Surgical experience.

**Licenses and Certifications Required**:

- Current state Registered Nurse license.
- Certified Clinical Documentation Specialist (CCDS) or certification within two (2) years of eligibility.

**Responsibilities**:
A day in the life of a **Clinical Documentation Specialist RN** at Hackensack Meridian Health includes:

- Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
- Performs admission reviews for specific patient populations using clinical documentation guidelines.
- Assists in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.
- Extensively reviews all physician and clinical documentation, lab results, diagnostic information and treatment plans and captures appropriate information on 3M 360 worksheet.
- Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption.
- Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified.
- Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
- Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
- Reviews medical record every 24-48 hours as appropriate.
- Updates 3M 360 worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate.
- Updates 3M 360 worksheet to reflect any changes in DRG and/or APR assignment.
- Communicates with physicians to ensure that requests for documentation have been noted.
- Confers with physicians to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
- Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in the patient's chart.
- As appropriate, documents and analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to leaders of Health Information.
- Follows established department process for follow-up reviews and physician communication.
- Reviews

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