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Clinical Documentation Specialist

4 weeks ago

Elk Mills, Maryland, United States Inova Health System Full time
Job Summary

We are seeking a skilled Registered Nurse to join our team as a Clinical Documentation Specialist. In this role, you will be responsible for improving the overall quality and completeness of clinical documentation within the inpatient medical record.

As a Clinical Documentation Specialist, you will work closely with physicians and the coding staff to ensure that the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients with DRG-based payer. You will also support timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Key Responsibilities:

  • Concurrent review of inpatient medical records throughout the patient's hospitalization
  • Analysis of clinical status of patient, current treatment, and past medical history to identify potential gaps in physician documentation
  • Communication with physicians or other providers to validate observations and prompt for documentation, if necessary
  • Proficient knowledge of HIMS standards of coding and application to ongoing evaluation of the medical record documentation
  • Identification of patients appropriate for Hospital Quality Measures and prompting RN and physician for clinical documentation according to accepted standards
  • Education of physicians and other key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
  • Review and clarification of clinical issues in the health record with the coding professionals to support an accurate DRG assignment, severity of illness, and/or risk of mortality
  • Identification of trends and/or opportunities to improve clinical documentation and presentation of opportunities and potential solutions to the clinical documentation initiative team
  • Attends coding/financial educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base
  • Demonstrate the highest level of confidentiality and conduct self-according to AHIMA Code of Ethics and ACDIS Code of Conduct
  • Perform assigned work safely, adhering to established departmental safety rules and practices, and report to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients, and visitors

Requirements:

  • Bachelor's degree in nursing
  • DE RN licensed or RN Compact State License
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred
  • RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable
  • Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable
  • Certified Clinical Documentation Specialist (CCDS) required within a year after eligibility

Benefits:

  • Holiday Pay
  • Guaranteed Hours
  • Continuing Education
  • 403b retirement plan
  • Pet insurance
  • Cancelation protection
  • Wellness and fitness programs
  • Mileage reimbursement
  • Employee assistance programs
  • Medical benefits
  • Dental benefits
  • Vision benefits
  • Benefits start day 1
  • License and certification reimbursement
  • Life insurance
  • Discount program