Registered Nurse Clinical Documentation Spec.

Overview

Registered Nurse Clinical Documentation Spec. role at Beacon Health System. Reports to the Director of Coding and CDI. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with ambulatory physicians and advanced practice providers to ensure that the clinical information within the medical record is accurate, complete, and compliant.

This includes accurate documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM specificity and medical necessity of ambulatory visits. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.

• Clinical Documentation Improvement (CDI) Practice – Maintains professional knowledge and competence in CDI. Review of medical records to ensure complete and accurate documentation to support assignment of ICD-10 codes required for billing, data, and regulatory requirements.
• Medical Record Review – Facilitates appropriate clinical documentation to support Hierarchical Condition Categories, ICD-10-CM specificity and medical necessity of ambulatory visits. Follows outpatient CDI processes for performing medical record reviews, identifying opportunities to improve provider documentation and querying physicians as needed to ensure that appropriate documentation appears in the medical record. Consistently meets established productivity targets for record review.
• Competency – Demonstrates knowledge of documentation requirements and coding guidelines that pertain to outpatient diagnosis coding to accurately reflect the complexity and medical necessity of the visit. Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews on a daily basis. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Education – Routinely provides one-on-one education to physicians, advanced practice providers and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient’s medical record. Interacts regularly with physicians in the outpatient setting, providing ongoing education regarding compliant documentation. Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
• Communication – Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s medical record. Collaborates with clinic and coding staff to resolve physician queries. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages open dialogue and maintains good rapport and cooperative relationships. Approaches conflict constructively and helps identify problems, offer solutions, and participate in their resolution.
• Professional Growth and Development – Demonstrates responsibility and accountability for personal development by participating in continuing education offerings. Maintains competence related to HCC documentation requirements, ICD-10-CM code assignment and coding guidelines.
• Technology – Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software and uses it as a resource to ensure accurate documentation.
• Travel – Utilizes personal vehicle to travel to ambulatory clinic sites to provide inquiries, formal and informal education to physicians and staff regarding clinical documentation updates, audit analysis, and to present audit/review findings.

• Contributes to the overall effectiveness of the department. Completes other job-related duties and projects as assigned.

• Attends and participates in…