RN - Clinical Documentation Specialist - Day Shift

4 weeks ago

Newark, Delaware, United States Christiana Care Full time
Job Details

RN Clinical Documentation Specialist
Day Shift (Hours: M-F 8 hours) Hybrid
Newark, DE

Christiana Care Hospital is seeking a skilled RN Clinical Documentation Specialist to improve the quality and completeness of clinical documentation within the inpatient medical record. This hybrid position requires remote and onsite work.

The RN Clinical Documentation Specialist will collaborate with physicians and coding staff to ensure accurate and compliant reimbursement and clinical severity capture. They will also support timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Additionally, they will educate the patient care team on documentation guidelines and serve as a clinical resource for the HIM coding department.

Key Responsibilities:
  • Concurrent review of inpatient medical records to identify potential gaps in physician documentation.
  • Communication with physicians to validate observations and prompt for documentation as needed.
  • Application of HIMS standards of coding to ongoing evaluation of medical record documentation.
  • Identification of patients for Hospital Quality Measures and prompting for clinical documentation.
  • Educating physicians and healthcare providers on clinical documentation improvement and accurate documentation.
  • Review and clarification of clinical issues in the health record with coding professionals.
  • Identification of trends and opportunities to improve clinical documentation.
  • Attending coding and financial educational programs to maintain knowledge base.
  • Performing assigned work safely and adhering to departmental safety rules.
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 of eligibility.
Knowledge, Skills, and Abilities:
  • Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
  • Knowledge of ICD and CPT coding nomenclature, UHDDS, and general coding principles.
  • Knowledge of CMS, JCAHO, and external regulatory and quality requirements.
  • Knowledge of Performance Improvement Principles.
  • Ability to work efficiently independently and with others.
  • Ability to utilize computer applications on various platforms.
  • Ability to manage multiple projects with constant shifts in priority.
Working Conditions:

Nursing Unit Environment - no patient contact

Normal Office Environment.

Frequent deadline situations

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