- Assesses clinical documentation through extensive review of the medical record to provide an accurate clinical picture of the patient including severity of illness, risk of mortality and resource utilization.
- Interacts with providers, nursing staff, other patient care givers, and coding staff to ensure the appropriate reimbursement is received for services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
- Conducts post discharge reconciliation for comparative analysis of CDI specialist and final coding MS/APR DRG.
- Formulates appropriate clinical documentation clarifications to improve documentation of principal diagnosis, comorbidities, present on admission (POA), hospital acquired conditions (HAC) and patient safety indicators (PSI). Query providers and APP's to clarify documentation in the EMR. The CDI nurse will maintain a query rate of at least 20% with a productivity rate average of 20 reviews per day (including new and follow up cases).
- Works with providers and Advanced Practitioners (APP) to improve provider's clinical documentation.
- Participates (by creating or conducting) in a type of departmental education, training and orientation sessions for the team (or others) per evaluation period.
- Assists in precepting new CDI nurses when needed and serves as a subject matter expert for CDI.
- Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
- Collaborates with healthcare team to ensure physician queries are resolved prior to discharge
- Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
- Working knowledge of Microsoft Office Suite including Excel, Word, PowerPoint and Outlook required
- Identifies ongoing documentation improvement opportunities
- Creates and manages review process and support tools.
- Upholding the Standards of Conduct and Corporate Compliance.
- Supports and assists the Quality department.
- Act as consultant to coding professionals when additional information or documentation is needed to assign coded data.
- Conducts post discharge reconciliation for comparative analysis of CDI specialist and HIM MS/APR DRG.
- Reviews clinical issues when appropriate with coding staff to assign a working DRG and/or clarification of documentation.
- Demonstrates initiative to improve quality and customer service by striving to exceed customer expectations.
- Institutes coaching sessions or corrective action plans as necessary.
- Proactively develops a reciprocal relationship with the Coding Professionals to ensure accuracy of diagnostic and procedural data through completeness of supporting documentation.
- Performs patient chart reviews during absences and when coverage is necessary. (EF)
- Queries providers and APP's to clarify documentation in the EMR.
- Precepts new CDI nurses and serves as a subject matter expert for CDI.
- Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
- Compose and initiate AHIMA compliant queries.
- Maintain personal and professional education and growth.
- Other duties as assigned.
- Associates Degree, Nursing (Required)
- Bachelors Degree, Nursing or healthcare related (Preferred)
- 5-6 years Acute Care Nursing (Required)
- 3-4 years CDI experience (Required)
- 2 years ICD-10-CM & ICD-10-PCS experience (Required)
- 1 year 3M 360 experience (Preferred)
- Strong verbal communication skills
- Knowledge of basic nursing principles and protocols.
- Proficient in clinical practice protocols for medical procedures and patient care.
- Time management and decision making skills. (Medium proficiency)
- Excellent organizational skills with an attention to detail
- Understanding the implications of new information for both current and future problem-solving and decision-making.
- Utilize extensive understanding of documentation requirements and guidelines in accordance with the Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
- Familiarity with the organization of medical records, medical terminology, and disease process
- Talking to others to convey information effectively.
- Ability to work effectively as team members with physicians and other staff.
- Ability to sit for extended periods of time.
- Able to establish good customer relationships with trust and respect
- Strong clinical assessment and critical thinking skills
- EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
- Registered Nurse (RN) - State Department of Health Professions Upon Hire(Required)
- CCDS (ACDIS) or CDIP (AHIMA) required Upon Hire (Required)
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Registered Nurse-Clinical Documentation Specialist III - Newport News, United States - Riverside Health System
Description
Newport News, Virginia
Facilitates the overall quality and completeness of provider-based clinical documentation in the medical record. Provides a thorough clinical review of the medical record to provide an accurate picture of the patient including severity of illness, risk of mortality and resource utilization. Serves as a subject matter expert in clinical documentation.
What you will do
Education
