RN CLINICAL DOCUMENTATION SPEC II

Minimum Offer

$ 33.07/hr.

Maximum Offer

$ 51.23/hr.

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: Neuro/Stroke Program

FTE: 0.90
Full Time
Shift: Days

Position Summary:
Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for caregivers in appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
* COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness
* CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines
* REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG. Present results of individual teaching case reviews to the attending physician(s) and/or department or division members
* PROBLEM-SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity, risk of mortality, length of stay. Train providers in the art of appropriate diagnosis descriptions to capture the abnormal signs and symptoms treated for all complications and co-morbidities for each patient as part of their normal documentation
* ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested. Identify department and/or specialty trends and patterns that show opportunities for improvements in documentations
* PHYSICIAN COMMUNICATION – Participate in clinical rounding and other communication with physicians and residents on the inpatient units to obtain/clarify specific principal diagnoses or comorbidities and complications that pertain to the clinical information shared on specific patients during rounding; assist the rounding team with clarification of appropriate documentation that identifies diagnoses vs. ill-defined clinical symptoms; facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
* COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Establish good working relationships with department Chairs and department Administrators to improve documentation
* PROCESS IMPROVEMENT - Analyze baseline outcomes; develop process improvement plans to improve baseline to a higher level of performance; prioritize and implement process improvement action plans; monitor results, and present results in a way to capture provider interest and motivate change in documentation practices
* REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software. Prepare Department and/or Division metrics reports for monthly meetings for areas assigned
* REPORT ANALYSIS – Create appropriate reports to demonstrate improvements in major complication and comorbidity (MCC) and/or complication and comorbidity (CC) capture rates. Use report analysis to demonstrate missed opportunities to appropriate capture the true severity of illness patients
* EDUCATION - Use query statistics and query type information to create training materials for physicians and ancillary staff. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coder query opportunities for MCCs and CCs
* LEADERSHIP - Demonstrate strong clinical documentation leadership skills to become a valuable CDI specialist for medical departments and divisions assigned

Qualifications

Education:
Essential:
* Bachelor's Degree
Nonessential:
* Master's Degree
Education specialization:
Essential:
* Nursing
Nonessential:
* Related Discipline

Experience:
Essential:
2 years directly related experience

Nonessential:
3 years directly related experience

Credentials:
Essential:
* RN in NM or as allowed by reciprocal agreement by NM
Nonessential:
* Certified Coding Specialist
* Certified Document Improvement Practitioner

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* Minor Hazard - physical risks, dirt, dust, fumes, noise
* Tuberculosis testing is completed upon hire and additionally as required