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Clinical Documentation Specialist
1 month ago
Eisenhower Health is seeking a skilled RN-Clinical Documentation Specialist to join our team. As a key member of our clinical documentation improvement team, you will play a vital role in ensuring the accuracy, completeness, and compliance of patient documentation.
Job Summary:The RN-Clinical Documentation Specialist will work closely with physicians, caregivers, case management, and coding staff to facilitate clinical documentation improvement. This includes providing on-going education and consultation to improve the accuracy, completeness, specificity, and compliance of in-patient acute care medical records.
Key Responsibilities:- Conduct concurrent review of medical records to identify areas of documentation requiring clarification of comorbidities, presence of complications, and opportunities to improve documentation from physicians to accurately assign the best DRG.
- Review 25-35 records in assigned areas within 24 hours or first working day after admission and maintain ongoing record review at least every 48 hours when necessary.
- Compile data in Midas and maintain monthly and quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance.
- Communicate with and work collaboratively with coding personnel to determine outcomes regarding severity/complexity and to assure all opportunities have been pursued before patients' discharge from acute care setting.
- Educate physicians and staff on Query tool as it relates to quality of documentation in the medical record.
- Develop and track, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation.
- Interface with physician champion regarding educational opportunities for specific documentation with physicians identified as needed additional education.
- Maintain compliance to HIPAA and all other regulations related to patient confidentiality.
- Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Improvement process and outcomes.
- Active California RN license
- Minimum of 5 years recent clinical nursing experience in an acute care setting
- Knowledge of MS-DRG methodology and inpatient coding rules and regulations
This is a full-time position working in a fast-paced acute care environment. The ideal candidate will have excellent communication and interpersonal skills, with the ability to work effectively in a team environment.
