Clinical Documentation Specialist - RN Required

Job Category:

Work Shift/Schedule:

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross, other payors as determined by CDI departmental goals). Ensures the accuracy and completeness of clinical information used for measuring and reporting Physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.
 

Minimum Job Qualifications

• Licensure or other certifications: Licensed to practice as an RN in Georgia

• Educational Requirements: Associates Degree

• Minimum Experience: Five (5) years in the practice of professional nursing.  

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: CCDS or CDIP

• Preferred Educational Requirements: Bachelor's Degree in Nursing. Additional education in Finance, Healthcare regulations and diagnoses-procedure coding.

• Preferred Experience: Experience in Healthcare Utilization and Revenue Management.

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Demonstrates aptitude in critical care or medical-surgical nursing

• Must demonstrate excellent observation skills, analytical thinking, problem-solving abilities, and excellent written and verbal communication by organizing work priorities and following standard of work

• Working knowledge of DRG coding optimization strategies and clinical documentation requirements are helpful

• Demonstrates interpersonal skills including professionalism practicing positive approaches to the position

• The position requires computer skills and the ability to be self-directed

• Familiar with ICD10 coding conventions, anatomy and  physiology, medical terminology, MSDRG reimbursement, coding software (preferably 3M 360 Encompass)

• Leadership skills are required

• Maintains requirements contained in Remote Agreement or forfeit the opportunity

Essential Tasks and Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing admission / continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines.

• Facilitates modifications to clinical documentation to ensure that appropriate severity of the patient is documented and to ensure appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer  (Medicare, Blue Cross and others as determined by CDI program goals)

• Conducts on-going follow-up reviews to ensure points of clarification have been recorded in the patient's medical record using department standard work to set workflow priority and scheduling..

• Works with Physicians concurrently, during the patient's stay, to educate and receive specific documentation pertinent to all requirements in question.

• Refers questionable quality, patient safety indicators, and utilization concerns to CDI Director, nursing and case management as indicated

• Writes queries to provide professional clinical inquiry about missing documentation (clinical indicators, diagnoses, or more descriptive) for conversion to codable terms following compliant, non leading format.

• Monitors the documentation against "core measure" quality indicators and addresses non-compliance documentation with Physicians and other appropriate staff.

• Interacts on a regular basis with Physician, nursing and case managers to ensure continuity of documentation.

• Works collaboratively with the coding staff to assign the "working" DRG to contribute for IDT Rounds.

• Processes all discharges by updating the DRG worksheet to reflect changes in patient status, procedures and/or treatments and concurs with the attending Physician to finalize diagnoses.

• Maintains a leadership role to ensure specific and compliant documentation is achieved recognizing its use in quality measures and reporting medical center and Physician outcomes.

• Educates various customer audiences on clinical documentation opportunities, coding, reimbursement and performance methodologies.

• Ensures documentation is meeting "medical necessity" for specific level of care and that services provided to the patient has a reasonably beneficial effect; refers cases to Utilization Review as indicated.

• Demonstrates a working knowledge of the DRG system and coding guidelines to facilitate recovery of appropriate payments for services rendered.

• Utilizes results of DRG analysis to have on-going dialogue with Physicians, nurses, coders, and case managers, to improve overall knowledge and performance.

• Participates in efforts to contain cost and/or generate revenue.

• Submits written ideas for reducing cost or adding revenue.

• Organizes and performs work effectively and efficiently by achieving daily reviews as assigned.

• Maintains and adjusts schedules to meet team performance and is willing to change workload or assignments as indicated.

• Meets assigned deadlines and departmental productivity standards.

• Assists with special projects as needed and all other duties as assigned.

• Maintains requirements in Remote Agreement in order to retain work from home opportunity.

• Work collaboratively with CDI team members to complete daily work of the team.

Physical Demands

• Weight Lifted: Up to 30 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 30 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Frequently 31-65%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.