Clinical RN Doc Improv Spec

Job Description - Clinical RN Doc Improv Spec )

Job Description

Clinical RN Doc Improv Spec -

Description

The Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through effective communication with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.

• Improves overall quality and completeness of clinical documentation by performing admission / continued stay reviews
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider
• Will utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation user for measuring and reporting physician and hospital outcomes.
• Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines and clinical expertise
• Tracks and trends specific opportunities for improvement through the query process
• Conducts educational sessions with physicians and other health care team members on documentation requirements
• Reviews clinical issues with physician advisors
• Participates in data collection for performance measures
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and ICD-10 Official Guidelines for Coding and Reporting
• Participates in department and facility Quality and Performance initiatives
• Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics
• Works in conjunction with the Directors of Case Management, Quality Improvement, Medical Staff Credentialing, and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement
• Prepares and presents educational programs using adult learning principles for identified improvement needs as indicated.
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans

• Must have current Nevada Registered Nurse License, RHIA, RHIT, CCS or combination thereof preferred. Prior experience in case management, clinical documentation improvement, and/or coding accuracy preferred.
• Minimum of three years’ experience in a clinical role and a minimum of one year experience with inpatient coding, process improvement in an acute care facility preferred or equivalent experience. Coding skills with experience in ICD-10, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic.
• Certified Documentation Improvement Specialist (CDIS) preferred
• Excellent oral, written and communication skills.
• Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians.
• Current working knowledge of one or more of the following:
  Medical /Surgical Nursing, Critical Care, Care and Case Management(Resource Utilization), Surgical Services, Prenatal Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data.
• Experience in development of reference based continuing educational programs using Adult Learning Principles
• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor.