RN - Registered Nurse- Clinical Documentation Improvement Specialist
? Reviews inpatient medical records within 24-48 hours of admission for a specified patient population toevaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and initiate documentation of the review.
? Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
? Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
? Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
? Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
? Consistently meets established productivity targets for record review.
? Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
? Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
? Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
? Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
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? Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
? Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
? Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
? Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
? Consistently meets established productivity targets for record review.
? Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
? Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
? Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
? Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Apply Now