- Communicating with Physicians verbally, and written will be required for 95% of the concurrent queries for documentation improvement. This includes follow up with physicians after initial chart reviews for the estimated MS-DRG or APR-DRG and processing of a query form for tracking.
- Formulating credible clinical documentation clarifications to improve clinical documentation of the principal diagnoses, major and minor co-morbidities, present on admission and quality core measures.
- Assigning a working MS-DRG or APR-DRG and utilization of the appropriate software for a query form. Utilization of the software for researching diagnoses having an impact on the MS-DRG or APR-DRG and severity of the patient.
- Analyzing clinical information to identify areas within the chart for potential gaps in physician documentation.
- Following up with any query after patient discharge that could not be obtained from the physician concurrently.
- Working with the physician advisor on a routine basis to collaborate on cases and advise on discussion that the physician advisor needs to have with selected physicians.
- Interpreting on-site reports, monitoring reports and data, and other tracking information and findings at team meetings.
- Identifying areas of focus through report analysis.
- Serving as a resource to physicians and administration regarding issues related to the appropriateness of an inpatient MS-DRG or APR-DRG assignment.
- Reviewing coder analyst feedback in the appropriate software program and individual DRG tracking system reports as a means of continuous self-evaluation; discusses any issues or concerns with the Manager or Director.
- Completing other job-related assignments and special projects as assigned.
- Participating on Beacon committees as requested.
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.
- The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a nursing program from an accredited school of nursing and a current license to practice as a Registered Nurse in Indiana. A minimum of five years of clinical experience in an acute care setting is required. A recent critical care or strong recent medical/surgical background is preferred.
- Ability to pass a written clinical competency exam.
- Requires ability to independently prioritize and organize work activities.
- Demonstrates knowledge of age-specific needs and the elements of disease processes and related procedures.
- Demonstrates the clinical knowledge and understanding of pathology/physiology to perform the essential functions of the position.
- Requires advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identification of variances in standards of care.
- Requires effective and appropriate verbal and written communication skills necessary to communicate effectively with physicians and receive the required documentation results from physicians for the program.
- Demonstrates strong interpersonal communication skills verbal and written necessary in interacting effectively with hospital staff and physicians.
- Demonstrates proficiency in effectively utilizing computer systems and applications (i.e., data entry, word processing and electronic spreadsheets) and the Internet, as well as the ability to operate office equipment specific to the department's needs (i.e, copier, fax machine, calculator, etc).
- Demonstrates the ability to maintain ethical standards as reflected by maintaining confidentiality of all information regarding patients, patient's families, staff and physicians.
- Will work some hours in an office environment.
- Works in patient care areas when making rounds to review medical records.
- May be exposed to patient illnesses and bio-hazards.
- Requires the physical ability and stamina to perform the essential functions of the position. Must be able to move throughout the hospital and patient care units.
-
Clinical Documentation Specialty RN
1 week ago
Beacon Health System Granger, United StatesFull-time 3245 Health Drive Professional Day Reports to the Director of Coding and CDET. Responsible for concurrent review of the clinical documentation in the medical records. Responsible to query the medical staff and other care givers as necessary via verbal and written commun ...
-
Private Duty Nurse overnight Schedule
3 weeks ago
Team Select Home Care Granger, United StatesJoin the _**Team Select Family**_ in providing quality home health care to our valued patients and their loved ones. With more than 35 locations across eleven states nationwide, Team Select Home Care aims to provide exceptional in-home patient care with new methods of reducing re ...
-
Patient Care Representative
4 days ago
TMJ & Sleep Therapy Centre Granger, United States**About TMJ & Sleep Therapy Centre** · In 2013, Dr. Daniel Klauer chose to limit his practice to treating patients with craniofacial pain, TMD and sleep disorders due to the overwhelming need within the community. During his years in general dentistry, Dr. Klauer learned to ident ...
-
Rn Field Nurse
2 weeks ago
Total In Home Services Mishawaka, United StatesTotal In Home Services is seeking a Registered Nurse to complete qaurterly visits with clients. Nurses will be compensated at $50 per visit. · **Responsibilities**: · - Schedule appointments. · - Coordinate with healthcare team members and document patient progress. · - Educate p ...
-
Psychiatric Nurse Practitioner
2 weeks ago
AIMS LLC Mishawaka, United StatesAIMS, LLC is a multi-specialty group practice providing inpatient psychiatric, medical hospitalist and psychology services to the NeuroPsychiatric Hospitals (NPH) throughout Indiana. NPH provides acute, inpatient psychiatric hospitalization for adult patients with a broad range o ...
-
Group Facilitator
3 weeks ago
Indiana Center for Recovery - South Bend Mishawaka, United StatesExcellent opportunity to join a great team · The Group Facilitator is responsible for conducting educational group sessions with our clients and supporting the mission of our organization. · Responsibilities/Qualifications: · 1. Provide education, process and supportive groups wi ...
-
Surgery Scheduler
3 weeks ago
OrthoAlliance MSO, LLC Mishawaka, United StatesSouth Bend Orthopaedics has an immediate opening for a full-time Surgery Scheduling Support Specialist. · **BASIC FUNCTIONS** · Utilizing excellent customer service and communication skills, answers incoming phone calls to the surgery scheduling department, either answering the q ...
-
Utilization Review Coordinator
1 day ago
Neuropsychiatric Hospitals Mishawaka, United StatesAbout Us**:_HEALING THE BODY AND MIND_** · Founded fifteen (15) years ago, NeuroPsychiatric Hospital is the largest hospital system in the nation providing care to patients with both neurological and medical needs. We are unique in that we serve a population which others have bee ...
-
Recreational Activity Associate
1 week ago
Neuropsychiatric Hospitals Mishawaka, United StatesAbout Us: · **_ HEALING THE BODY AND MIND._** · Founded fifteen (15) years ago, NeuroPsychiatric Hospitals is the largest hospital system in the nation providing care to patients with both neurological and medical needs. We are unique in that we serve a population which others ha ...
-
Registered Nurse, Per Diem
1 week ago
Indiana Center for Recovery - Mishawaka Mishawaka, United StatesOur Team is dedicated to delivering our clients the most comprehensive, beneficial substance abuse services available. Our goal is to provide our clients with the best opportunity for long term sobriety. · **Responsibilities/Qualifications**: · - Reviews patient/resident status t ...
-
Pca Personal Care Assistant
3 weeks ago
Nurses at heart home care LLC Elkhart, United States**About us** · Nurses at heart home care LLC is a small business in Elkhart, IN. We are professional, agile, and our goal is to Is to provide positive, effective, and sufficient care in the comfort of our clients home... · Our work environment includes: · - In-Home setting · **Re ...
-
Warehouse Laborer
2 weeks ago
Ervin Cable Elkhart, United StatesOverview: · A successful Warehouse Laborer shall receive, issue and maintain telecommunication construction equipment and materials; keep accurate inventory records and submit information regarding warehouse inventory levels to supervisor and/or customer as requested. At a minimu ...
-
Corporate Accountant Assistant
2 weeks ago
Neuropsychiatric Hospitals South Bend, United StatesAbout Us: · **Corporate Accountant Assistant (AP/AR) | NeuroPsychiatric Hospitals | South Bend, IN** · **HEALING THE BODY AND MIND** Founded fifteen (15) years ago, **Neuropsychiatric Hospitals** is the largest hospital system in the nation providing care to patients with both ne ...
-
Referral Coordinator
1 day ago
HealthLinc South Bend, United StatesAs a Referral Coordinator, you will act as a liaison between patients, our providers, and specialty sites; check patient eligibility and maintain accurate and timely documentation. This position will report to the Assistant Site Operations Director. · **JOB RESPONSIBILITIES**: · ...
-
Tester
5 days ago
River Bend Hose Specialty, Inc. South Bend, United States**Company Overview** · River Bend Hose Specialty is a value-added industrial distributor/manufacturer, which has been serving the Michiana and broader region for over 40 years. Our goal is to continue to establish and maintain our respected reputation with our customers and suppl ...
-
Home Infusion Nurse
1 day ago
AvevoRx, LLC South Bend, United States**Infusion Nurse, RN** · **Job Overview**: · **Responsibilities**: · - Performs direct and indirect patient care in the home or alternate site setting. · - Assess patient during initial visit for current medical and psychosocial needs. · - Develop plan of care and treatment. Coll ...
-
Rn Home Health Aide Trainer
4 days ago
Ability Home Health South Bend, United StatesOverview: · We are seeking an RN who can do home health aide trainings in the office 5-10 hours/ week. Will be a contracted position. · MUST HAVE 1 year of home health experience and 1 year of RN experience. · **Duties**: · - Schedule home health aides to come into the office for ...
-
Assembly Associate
1 day ago
ACTIA Corporation Elkhart, United StatesACTIA Corporation has been manufacturing quality vehicle electronics and diagnostic equipment for growing markets such as Off-Highway, Bus & Coach, Truck & Fleet, Marine and Specialty Vehicles for over 30 years. ACTIA Group is an international group based in Toulouse, France. · W ...
-
Barista - White Birch
4 days ago
Four Winds Casino and Resort South Bend, United States**SUMMARY**: · Responsible for providing dining service to all guests in an efficient, courteous and professional manner, displaying a high standard of guest services. · **ESSENTIAL DUTIES AND RESPONSIBILITIES** include the following: · - Delivers prompt, efficient and courteous ...
-
General Tradesperson
2 weeks ago
Corewell Health Benton Harbor, United States**Job Summary** · Provides a safe and aesthetically pleasing environment through refreshing different spaces throughout the healthcare system under the direction of a supervisor. Participates in the overall building management program to provide high-quality, cost-effective servi ...
Clinical Documentation Specialty RN - Granger, IN, United States - Beacon Health System
Description
Full-time3245 Health Drive
Professional
Day
Reports to the Director of Coding and CDET. Responsible for concurrent review of the clinical documentation in the medical records.
Responsible to query the medical staff and other care givers as necessary via verbal and written communication, to obtain accurate and complete documentation which appropriately supports the severity of the patient's illness and risk of mortality.
MISSION, VALUES and SERVICE GOALS*MISSION: We deliver outstanding care, inspire health, and connect with heart.
*VALUES: Trust. Respect. Integrity. Compassion.
*SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Collaborates with physicians for documentation of appropriate clinical diagnoses by:
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements: