- Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
- Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation
- Maintains positive open communication with physicians, nursing and all other disciplines involved in the care of the patient
- Works closely with HIM Coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care
- Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures
- Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis
- Consistently meets established productivity targets for record review
- Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation
- Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies
- Assists in collection and organization of data for analysis by appropriate medical and hospital committees
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
- Demonstrates competence to perform assigned responsibilities is a manner that meets the population-specific and developmental needs of the members served by the department
- Appropriately adapts assigned assessment, treatment, and/or service methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each member served
- Takes personal responsibility to ensure compliance with all policies, procedures and standards as promulgated by state and federal agencies, the hospital, and other regulatory entities
- Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties
- Performs other duties as assigned
- Associate's Degree in Nursing
- RN License in state of employment or compact
-
Registered Nurse
3 weeks ago
Aequor Irving, United StatesHighlights · Location Irving, TX (2) · Pay Rate Up to: $1356.80/Week · Start Date Jun 3, 2024 to Aug 24, 2024 · Duration 12 Week · Number of Positions 1 · Remote Position Type On-Site Work Only · Shift Type Days · Hours Per Day 8 Hours · Discipline Registered Nurse (RN) ...
-
Registered Nurse
1 week ago
HarmonyCares Irving, TX, United StatesRegistered Nurse - Per Visit · Overview · HarmonyCares is one of the nation's largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Me ...
-
Registered Nurse
3 days ago
TLC Nursing Irving, United StatesJob Description · Job DescriptionProfession: Registered Nurse (RN) · Location: Irving Texas · Specialty: L&D · Unit: · Gross Pay: 921.6 · Schedule: Nights - 3 x 12, 19:00:00-07:00:00, · Guaranteed Hours: 36 · Openings: 1 · Start Date: 06/03/2024 · End Date: 09/02/2024 · Assignm ...
-
Registered Nurse
1 week ago
HarmonyCares Irving, Texas, United States PermanentOverview: · HarmonyCares is one of the nation's largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home ...
-
Registered Nurse
2 weeks ago
All Med Search Irving, United StatesJob Description · Job DescriptionRegistered Nurse RN Emergency Department · We have openings for Registered Nurse (RN) Emergency Room (ER) in the following locations: · Plano, Denton, Fort Worth, Lewisville, North Richland Hills, Irving, McKinney, Dallas, San Antonio, Alpine, Ar ...
-
Registered Nurse
1 week ago
Baylor Scott & White Health Irving, TX, United States Full timeJoin Baylor Scott and White Medical Center - Irving as a Registered Nurse and be part of something better · $10,000 sign-on bonus available to full-time candidates with 2 years Acute Care experience · Labor and Delivery · Our Labor and Delivery unit is a fast-paced environment ...
-
Registered Nurse
2 weeks ago
All Med Search Irving, United StatesJob Description · Job DescriptionShift: Days - with rotating weekends · Night Shift Differential: $3.75/hr. Weekend Differential: $4.30/hr. · Sign-on bonus: $10,000 · Relocation: up to $3,000 · Position Summary: · The Registered Nurse - Intensive Care Unit RN ICU provides direct ...
-
Registered Nurse
1 week ago
DaVita Inc Irving, TX, United StatesRegistered Nurse · 204 E Airport Freeway, Irving, Texas, 75062, United States of America · DaVita is seeking a Nurse who is looking to give life in an outpatient dialysis center. You can make an exceptional difference in the lives of our patients and their families dealing with e ...
-
Registered Nurse
2 weeks ago
Aequor Irving, United StatesHighlights · Location Irving, TX · Start Date Jul 31, 2024 to Jun 5, 2025 · Duration 2 Week · Number of Positions 1 · Remote Position Type On-Site Work Only · Shift Type Days · Hours Per Day 8 Hours · Discipline Registered Nurse (RN) · Skills · School · ...
-
Registered Nurse
1 week ago
DaVita Inc Irving, TX, United StatesRegistered Nurse · 204 E Airport Freeway, Irving, Texas, 75062, United States of America · DaVita is seeking a Nurse who is looking to give life in an outpatient dialysis center. You can make an exceptional difference in the lives of our patients and their families dealing with e ...
-
Registered Nurse
3 weeks ago
Innovative Renal Care Dallas, United StatesRegistered Nurse, PRN · Our Registered Nurses provide high quality patient care to patients suffering from the most advanced stage of chronic kidney disease, known as End Stage Renal Disease (ESRD). Nurses are on the front line of patient care, improving the quality of life of ev ...
-
Registered Nurse
3 weeks ago
Floyd HomeCare of Cartersville Dallas, United States Full timeWe are hiring for a Registered Nurse (RN). · At Floyd HomeCare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families, each other, and the communities we serve—it tr ...
-
Registered Nurse
3 weeks ago
Innovative Renal Care Dallas, United States Full timeRegistered Nurse, RN · Our Registered Nurses provide high quality patient care to patients suffering from the most advanced stage of chronic kidney disease, known as End Stage Renal Disease (ESRD). Nurses are on the front line of patient care, improving the quality of life of eve ...
-
Registered Nurse
2 weeks ago
The Fortus Group, Inc. Arlington, TX, United StatesFortus Healthcare Resources is seeking a Travel MOTHER BABY Registered Nurse for an immediate opening in ARLINGTON, TX . Registered Nurse, Registered, Nurse, Healthcare, Staffing ...
-
Registered Nurse
1 week ago
DaVita Inc Arlington, TX, United StatesRegistered Nurse · 1785 S Hayes St, Arlington, Virginia, , United States of America · DaVita is seeking a Nurse who is looking to give life in an outpatient dialysis center. You can make an exceptional difference in the lives of our patients and their families dealing with end-st ...
-
Registered Nurse
1 week ago
Encompass Health Rehabilitation Hospital of Arlington Arlington, TX, United StatesRegistered Nurse · Registered Nurse Career Opportunities · Competitive base rate, generous shift differentials, career ladder · Current opportunities for: · Full Time, Day Shift (Benefits start on Day 1 of employment, PTO accrual starts day 1, 7 paid holidays) · PRN, Day Shift or ...
-
Registered Nurse
3 weeks ago
Res-Care, Inc Arlington, TX, United StatesRegistered Nurse · Our Company · ResCare Community Living · Overview · Join a team of passionate and caring clinicians who make a difference in people's lives. Our nursing group focuses on compassion and meeting the needs of our clients in a variety of settings. If your passion i ...
-
PACU Registered Nurse PRN
3 weeks ago
Park Central Surgical Center Irving, United StatesDescription · Introduction · Do you have the PRN career opportunities as a PACU Registered Nurse PRN you want with your current employer? We have an exciting opportunity for you to join Park Central Surgical Center which is part of the nation's leading provider of healthcare ser ...
-
Emergency Department Registered Nurse
2 weeks ago
Medical City Dallas Irving, United StatesIntroduction · Are you looking for a place to deliver excellent care patients deserve? At Medical City Dallas we support our colleagues in their positions. Join our Team as an Emergency Department Registered Nurse and access programs to assist with every stage of your career. · T ...
-
Hospice Registered Nurse
2 hours ago
Advanced Hospice Irving, United StatesJob Title/Position: Hospice Registered Nurse (RN) · Reports to: Clinical Manager/Clinical Director · Position Summary: · The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. ...
Clinical Documentation Registered Nurse II - Irving, United States - CHRISTUS Irving Corporate Office
Description
Job Description
Summary:
This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.
Responsibilities:
Requirements: