Clinical Documentation Specialist

3 days ago

Hartford, Connecticut, United States Connecticut Children's Full time
Utilization Review Nurse Job Description

The utilization review nurse plays a crucial role in ensuring the quality, completeness, and accuracy of clinical documentation. This involves extensive interaction with physicians, nursing staff, case managers, patient caregivers, and Health Information Management coding staff to guarantee that clinical documentation reflects the clinical treatment, decisions, diagnosis, and level of service rendered.

Responsibilities:
  • Perform admission, concurrent, and retrospective medical reviews to provide reimbursement information to payers.
  • Act as a liaison between hospital departments, medical staff, and payers on issues related to medical necessity for admission and continued stay.
  • Maintain open communication with physician advisors and provide education to clinical staff as needed.
  • Apply standardized criteria and guidelines to determine appropriateness of admissions and assignment of patient class.
  • Assist in monitoring wasted resources while maintaining high-quality care and ensure compliance with Medicare and Medicaid regulations.
  • Act as a resource for the Care Management department regarding utilization, insurance, and payer issues.
  • Identify potential problems regarding payment eligibility for clinical services and recommend corrective action.
  • Participate in UR meetings.
Qualifications:
  • Education: BSN degree required.
  • Experience: Minimum of 3 years of pediatric clinical experience required.
  • Knowledge, Skills, and Abilities:
    • Knowledge of pathophysiology and disease process.
    • Working knowledge of clinical information.
    • Familiarity with clinical care to establish credibility with physicians, nurses, and other members of the front-line care team.
    • Ability to provide clinical and financial education to colleagues, patients, and families.
About Us:

Connecticut Children's is a health system dedicated solely to children. With over 100 years of legacy, we offer personalized medical care in more than 30 pediatric specialties across Connecticut and two other states. Our commitment to diversity, equity, and inclusion provides a welcoming environment for our patients, families, and team members.

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